Approach Considerations
Diagnosis is primarily based on the clinical findings and the chronology of the development of lesions.
There are no routine hematologic or blood chemistry laboratory investigations needed in the workup of a patient with chemotherapy-induced oral mucositis.
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.
Particularly in hematopoietic cell transplantation (HCT) patients, biopsy is indicated 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. Biopsy should also be considered when oral ulcerations are exacerbated with engraftment and restoration of the WBC count, especially when skin changes are absent, because this is suggestive of emerging acute graft versus host disease (GVHD). However, biopsy is not routinely necessary for oral mucositis.
There is no indication for ordering imaging studies in a patient with suspected chemotherapy-induced oral mucositis.
Oral mucositis should be assessed routinely using a validated instrument. The 2 most commonly used are the World Health Organization (WHO) Oral Toxicity score and the National Cancer Institute (NCI) Common Common Terminology Criteria for Adverse Events (CTCAE) 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, version 5.0 is based entirely on function (what a patient is able to eat). [17] 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. [18]
Of note, symptoms may precede objective findings by 1-3 days and therefore can serve as an important prognostic indicator.
Histologic Findings
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.
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Hairy tongue.
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Multiple mucoceles on the hard palate.
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Erythematous oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
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Ulcerative oral mucositis lesions on the labial mucosa and the floor of the mouth.
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Oral pseudomembranous candidiasis on the hard palate.
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Herpes simplex virus ulceration on the dorsal surface of the tongue.
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Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
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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.
