Copyright B 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Faith Gibson, MSc, PhD, RSCN RGN Cert Ed

RNT, FRCN
Elizabeth M. Auld, RGN, RSCN, DipN
Gemma Bryan, MSc (Human Nutrition)
Suzanne Coulson, RSCN
Jean V. Craig, MSc, PhD, RSCN, RGN
Anne-Marie Glenny, MMedSci, PhD

A Systematic Review of Oral

Assessment Instruments
What Can We Recommend to Practitioners in Children’s and
Young People’s Cancer Care?

K E Y W O R D S Background: Observing and recording the signs and symptoms of oral mucositis
Adolescence are an important part of oral care, essential to the prevention and treatment of
Children mucositis. Structured oral assessment enables a more informed and accurate
Mucositis measurement identification of signs and symptoms and will enable early and individualized
Oral mucositis interventions. Objective: A United KingdomYbased mouth-care group
Review conducted a systematic review of the published literature through to March 2004
Systematic and repeated in 2008. The goal of this review was to identify and evaluate the range
of instruments used to assess oral mucositis to recommend in evidence-based
guidelines the ‘‘best’’ instrument to use in the field of children’s and young people’s
cancer care. Methods: Search sources included the Cochrane Library, MEDLINE,
EMBASE, and CINAHL. Studies were selected using defined criteria and reviewed
by 3 pairs of group members. Results: Fifty-four individual oral assessment
instruments were identified with only 15 reporting evidence of reliability and validity
testing. Only 3 articles reported on oral assessment exclusively in our population.

Author Affiliations: Great Ormond Street Hospital for Children NHS Correspondence: Faith Gibson, MSc, PhD, RSCN RGN Cert Ed RNT,
Trust and London South Bank University at Department of Children’s Nursing, FRCN, Department of Children’s Nursing, Faculty of Health & Social Care,
Faculty of Health & Social Care, London South Bank University London, London South Bank University, 103 Borough Rd, London SE10AA, UK
England (Dr Gibson); Manchester Children’s Hospitals, Pendlebury, Man- (Gibsof@gosh.nhs.uk; faith.gibson@lsbu.ac.uk).
chester, England (Ms Auld); School of Nursing Midwifery and Social Work, Accepted for publication November 12, 2009.
University of Manchester, Manchester, England (Ms Bryan); Paediatric
Oncology and Haematology, St James’s Hospital, Leeds, UK (Ms Coulson);
Evidence-Based Child Health Unit, Institute of Child Health, University of
Liverpool, Alder Hey Children’s NHS Foundation Trust, Liverpool, England
(Dr Craig); Evidence Based Oral Health Care, School of Dentistry, University of
Manchester, Manchester, England (Dr Glenny).
Written on behalf of the Children’s Cancer and Leukaemia Group and
Paediatric Oncology Nurses Forum Mouth Care Group.
The Children’s Cancer and Leukaemia Group is funded by a grant from
Cancer Research UK, and the ongoing work of the Mouth Care Group is
supported by CLICSargent.

Oral Assessment Instruments Cancer NursingTM, Vol. 33, No. 4, 2010 n E1

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 Conclusions: The guidelines recommend only 1 assessment instrument,
the Oral Assessment Guide, or adaptations of this instrument, to be used in clinical
practice. Five factors influenced this recommendation: purpose of assessment,
population, outcomes assessed, and quality of the instrument and ease of use.
Implications for Practice: The Oral Assessment Guide has been consistently
judged to be user-friendly and appropriate for everyday clinical practice with both
adults and children, as well as a useful research tool.

T
reatment of childhood cancer is becoming increasingly
effective, with survival rates reported at 70% to 75% in
parts of Europe and North America.1 Despite advances
in chemotherapy and radiotherapy, cancer treatment remains as-
sociated with clinically important, sometimes treatment-limiting,
adverse effects. Oral mucositis is a common consequence of
treatment, occurring in approximately 30% to 75% of patients,
depending on treatment type.2,3 In about 50% of patients with
mucositis, lesions can be severe causing significant pain, in-
terfering with nutrition, and sometimes requiring modification
of the chemotherapy regimen. In addition, mucositis may pre-
dispose a child to fungal infection (most commonly candidiasis),
viral infection (eg, herpes simplex virus), and bacterial infection,
which may lead on to life-threatening systemic infection. This
sequel of cancer treatment is important as it can impact severely
on a patient’s quality of life4 and may limit delivery of cancer
treatment.5 Oral complications remain one of the most chal-
lenging cancer-related symptoms to manage.
Observing and recording the signs and symptoms of oral
mucositis are an important part of oral care that are essential to
the prevention and treatment of mucositis.6,7 Structured oral
assessment enables a more informed and accurate identification
of signs and symptoms and will enable early and individualized
interventions that may decrease the risk of secondary problems
such as septicemia and pain.8Y10 In addition, the effectiveness of
interventions can be clearly articulated when ongoing assess-
ment is central to an oral care protocol.9 Better defining oral
assessment can also help clarify terminology and provide ac-
curate descriptions of a child’s oral status. Structured symptom
assessment has shown to result in health professionals having a
greater awareness of patients’ experience of cancer-related symp-
toms.11 Yet, in a telephone survey conducted by the authors of
this article, only 16 of the 22 UK Children’s Cancer and
Leukaemia Group (CCLG) centers reported using an oral as-
sessment scale. Assessment was primarily undertaken by nursing
staff.12 Although there is evidence supporting the benefits of
systematic examination of oral status, the use of oral assessment
instruments has failed to be universally implemented into
clinical practice.
Clinical guidelines have been viewed as a way of helping to
promote research-based practice, thus encouraging clinical prac-
tice to be based on relevant, scientifically rigorous research evi-
dence.13,14 The CCLG and the Paediatric Oncology Nursing
Forum (PONF) of the United Kingdom established a subcom-
mittee to look at mouth care and develop comprehensive
evidence-based guidelines to aid decision making in this area.
These guidelines aim to establish the most effective oral care
strategies, as indicated by the best available research evidence.
As part of the development of these guidelines, a systematic
review was conducted to determine the evidence relating to
methods of oral assessment. This review will present the process
undertaken to identify and evaluate the range of instruments
used to assess oral mucositis to recommend the ‘‘best’’’ in-
strument to use in the field of children’s and young people’s
cancer care.
n Materials and Methods
A guideline development panel, constituting members of the
CCLG-PONF Mouth Care Group, was established. This in-
cluded pediatric oncologists, dentists, pediatric oncology nurses,
a dental hygienist, a statistician, and research methodologists
with experience in systematic reviews. The guidelines were de-
veloped, where possible, following methods outlined by the
Scottish Intercollegiate Guidelines Network (SIGN).15 Initially,
a consensus approach was used to establish the scope and basic
structure of the guidelines. Three key areas were addressed
within the guidelines: methods of oral assessment, dental care
and basic oral hygiene, and drugs and therapies.
Only the review pertaining to the methods of oral assess-
ment will be detailed in this article. A report describing the
development of the guidelines in general is available.16
Preliminary Search
An initial search was undertaken for 3 reasons: to gain an
overview of the volume of literature, to inform the research
questions, and to establish the research methodologies used
within the area. This search did not seek to identify all relevant
information but aimed to provide the basis on which to make
certain organizational and methodological decisions with re-
gard to the guideline development process. The search was run
on MEDLINE (OVID Biomed 1966 to January 2002).
Seventy-eight records were identified and distributed to the
assessment subgroup of the guideline panel. This subgroup
liaised by e-mail/telephone to formulate a list of questions to be
addressed in the guidelines. These questions were circulated to

E2 n Cancer NursingTM, Vol. 33, No. 4, 2010 Gibson et al

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the guideline panel for further comments. The research ques-
tions identified were the following:
1. What are the most appropriate methods of surveillance?
2. What oral assessment instruments are available, and how
reliable and valid are these tools?
3. What areas of the mouth should be assessed?
4. What equipment should be used when examining the mouth?
5. What is recognized as normal?
6. Who should undertake oral assessment?
7. How often should a child’s mouth be assessed?
8. How should assessment be taught and quality reviewed?
9. How should assessment influence decision making and then
management?
10. How can assessment be used to monitor response to therapy?
11. How far is the assessment process acceptable to children/
teenagers?
Detailed Searches
Following the identification of the research questions, a second
round of literature searching was undertaken. The following
electronic databases were searched: the Cochrane Library (issue
2, 2004), MEDLINE (OVID Biomed 1980 to March 2004),
EMBASE (OVID Biomed 1980 to March 2004), and CINAHL
(OVID Biomed 1980 to March 2004). The search was adapted
for each database searched. In addition, randomized controlled
trials (RCTs) and systematic reviews identified for the drugs and
therapies section of the guideline were also screened to identify
any assessment instruments not identified through the electronic
searches.
The literature searches were repeated in March 2008, prior to
a revision of the guidelines. Once again, the following electronic
databases were searched: the Cochrane Library (issue 2, 2008),
MEDLINE (OVID Biomed 1980 to March 2008), EMBASE
(OVID Biomed 1980 to March 2008) and CINAHL (OVID
Biomed 1980 to March 2008).
Inclusion Criteria
Studies describing oral assessment instruments used in patients
(adults or children) treated for cancer with chemotherapy and/
or radiotherapy or studies investigating the validity, reliability,
or utility of these instruments or any other aspect of oral as-
sessment in this patient group were eligible for inclusion. Stud-
ies were excluded if they focused more generally on quality of
life rather than oral assessment.
Assessment of Relevance
An initial screen of titles and abstracts was carried out by a
single reviewer. Articles clearly not relevant to the topic of oral
assessment were excluded at this stage. The titles and abstracts
of all remaining studies were distributed for screening in
duplicate by 2 independent reviewers, and the full paper copies
of all potentially eligible publications retrieved and assessed for
eligibility. Copies of assessment instruments referred to in the
publications but not already located through the electronic
Oral Assessment Instruments
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
searching were retrieved. The repeat search and screening of
titles and abstracts were carried out by a single reviewer.
Quality Assessment and Data Extraction
This was carried out by reviewers working independently and
then assimilated by reviewers working in pairs. Data on oral
assessment instruments were extracted and tabulated to
provide a description of the following:
1. components covered (eg, lips);
2. signs recorded (eg, dry, cracked);
3. grading system used for each sign;
4. whether objective or subjective measures were used for each sign;
5. whether a compound score was presented;
6. whether the population of interest was adults, children, or both;
7. whether any reliability testing was undertaken; and
8. whether any validity assessment was undertaken.
Any studies providing some form of validity or reliability test-
ing were subsequently assessed using an adaptation of the SIGN
Diagnostic Studies Checklist.15 Disagreements in the data extrac-
tion and assessment process were taken to a third party.
n Results
A total of 410 publications were identified by the initial search;
333 were excluded because of type of participants and/or
interventions not fulfilling the eligibility criteria, leaving 77
eligible for inclusion. Another 40 publications were excluded as
these were studies not reporting on oral assessment instruments.
Eleven instruments were further excluded because of being
duplicates of previously published instruments or not instru-
ments for assessing the oral cavity (eg, assessing quality of
life).3,17Y26 A total of 391 additional publications were iden-
tified during the repeat search. Thirty-one of which were eli-
gible for inclusion. Three of these publications were further
excluded because of duplication or because they were assessing
general lifestyle and not oral assessment.27Y29 The Figure shows
the selection process.
No studies were identified with regard to the most ap-
propriate timing or frequency of oral assessment or personnel to
conduct the oral assessment. Similarly, the acceptability of the
assessment process to the child/young person was not addressed
in the identified literature.
Fifty-four oral assessment instruments are included in this
review (Table 1; Refs. 30Y83). The methods of assessment in-
cluded visual observation, auditory observation, palpation, the
use of a spatula and a ruler (for measuring the size of lesions),
stimulated/unstimulated saliva collection, and self-assessment
by the patient. Several studies reported the importance of good
lighting when conducting the oral assessment. The signs
recorded for each component and the grading system used
varied across all assessment instruments. Twenty-five in-
struments required the calculation of a compound score
(based on the scores of individual components/signs and
symptoms).30,31,33,39,45Y48,50,51,54,57,59,62,64Y67,69,72,74,76,78Y80
Cancer NursingTM, Vol. 33, No. 4, 2010 n E3
Figure n Flow diagram showing the number of references identified, retrieved, and included in the review.
While many of the calculations were straightforward and hence
would be described as easy to use, 4 instruments required com-
plex calculations to be carried out, precluding the instrument
from use in everyday clinical practice.33,69,70,72 One tool used a
set of complex grading rules to assign a grade,59 limiting the use
of this instrument in everyday clinical practice and necessitating
extensive training of personnel prior to its use in research. While
we recognize that the future development of targeted growth
factors may well necessitate more complex assessment of mu-
cosal injury, this instrument59 in its current format would not
be considered the instrument of choice in children’s cancer
care because of its complexity and its reliance on sustained
observation of the oral cavity.
Three instruments were identified reporting entirely patient-
generated scores.54,61,71 Stiff and colleagues71 developed the
Oral Mucositis Daily Questionnaire to assess the impact of
mucositis on pain and daily functioning in patients undergoing
stem cell transplantation. This is composed of 6 questions,
including 3 visual analog scales (VASs), and asks patients about
their overall oral health, the amount of mouth and throat
soreness they have experienced over the previous 24 hours, and
whether this soreness had limited any of 5 daily activities
(swallowing, talking, eating, drinking, and sleeping). The final
2 questions concern patient reports of diarrhea.71 The instru-
ment of Kushner and colleagues54 uses VASs to record patient
reports. Ten questions are asked about mouth pain; restriction
of speech; difficulty eating (hard foods, soft foods); difficulty
in, and restriction of, drinking due to mouth sores; difficulty
in swallowing; and taste changes. This instrument was also
E4 n Cancer NursingTM, Vol. 33, No. 4, 2010
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
developed for use in stem cell transplant patients, but unlike
the Stiff et al instrument, the Kushner et al54 instrument asks
patients to recall the condition of their mouth over the
previous week. The instrument of Öhrn and colleagues61 also
uses VASs to ask 10 questions about the patient’s level of pain,
mouth dryness, salivary viscosity, ability to talk and perform
oral hygiene, dysphagia, taste alterations, the condition of the
lips and gingiva, and whether the patient feels he/she has a
clean mouth. This instrument has been used weekly alongside
the Oral Mucositis Index66 in a mixed sample of chemo-
therapy and radiotherapy patients.61
Fifteen studies were identified as providing some assessment
of the quality of the instruments through a process of validity
and/or reliability testing.39,45,46,48,51,54,59,64,69Y72,74,77,78 One
instrument could not be assessed for validity and reliability
because of the initial source being unavailable and the related
article having no validity information.36 An evaluation of these
studies, using an adaptation of the SIGN Diagnostic Studies
Checklist,15 is presented in Table 2. Seven studies avoided
selection bias by either enrolling consecutive series of patients
or patients chosen at random from a suitable popula-
tion39,46,48,64,69,71,74 All except one of the studies was felt to
include participant’s representative of those on whom the test/
assessment instrument would be used. This study involved
only adults receiving hematopoietic stem cell transplant but
suggests that further testing should be carried out with patients
receiving other forms of therapy.64
With regard to the validity of instruments assessed, only 6
studies reported on face validity (whether an instrument appears
Gibson et al
to measure what it is supposed to measure)51,54,59,64,69,70;
however, all studies were felt to measure the condition of
the mouth. Eight studies reported good content validity (referring
to the comprehensiveness of the instrument).39,45,48,51,59,64,69,77
Only 6 studies reported on criterion validity (comparing a scale
with some other measure), considered the most rigorous of
validity testing, by comparing the results to a reference stand-
ard.54,59,70,71,77,78 The Western Consortium for Cancer Nursing
Research (WCCNR) Staging System77 was compared with the
Oral Assessment Guide (OAG)48 and the World Health
Organization (WHO) grading system for mucositis.81Y83 Findings
of the study showed that the WCCNR had good convergent
validity with both the OAG and the WHO scales. The authors
report that the WCCNR staging system ‘‘reflects expert practice,
encouraging clinicians to make a holistic assessment of the
mouth’s condition rather than summing scores on discrete aspects
of the oral condition.’’
Four instruments assessed construct validity (to determine
whether the instrument measures the theoretical construct it pur-
ports to measure).54,59,70,72 Spijkervet and colleagues70 assessed
construct validity measuring correlation between the instrument
and weight loss/feeding problems. Although correlation was
observed, this may relate to nausea/vomiting rather than (or in
addition to) mouth condition. Sung and colleagues72 also re-
ported construct validity, when validating the Oral Mucositis
Assessment Scale (OMAS)69 for use with children. Correlation
was measured between the instrument, the number of doses of
topical analgesia, total cumulative dose of opioid analgesia, and
the receipt of total parenteral nutrition. Correlation with each
of these clinical outcome measures was described as fair only.
McGuire and collegues59 assessed construct validity measuring
correlation between the instrument and 2 pain scores from the
Brief Pain Inventory84 using Pearson product moment corre-
lations. Sixteen of the 18 correlations were statistically signifi-
cant. Kushner and collegues54 also reported construct validity by
comparing the instrument to 4 quality-of-life instruments and
reported that the Patient-Reported Oral Mucositis Symptom
scale was significantly correlated with the Center for Epidemio-
logic Studies Depression scale.85
Ten studies measured interrater reliability,39,45,48,59,64,69,70,72,74,78
and all showed high levels of agreement between observers.
Only 3 studies presented data on intrarater reliability.59,71,74
Stiff and colleagues71 repeated assessments 24 hours later, while
the duration between assessments was unclear in the reports of
both Tardieu et al74 and McGuire et al.59
Four assessment instruments were identified for use in chil-
dren and young people.39,50,51,72 However, only 3 of these instru-
ments provided validity and reliability information.39,51,72 All 3
studies reported on the use of instruments initially developed in
the adult population. Two of the studies reported on the use of
the OAG48 in children,39,51 and 1 study72 reported on the OMAS.69
n Discussion
The goal of this review was to evaluate the range of instruments
used to assess oral mucositis. The intention was to synthesize
Oral Assessment Instruments
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and present a summation of the evidence in the guidelines and
recommend to professionals the best instrument available to use
in children’s and young people’s cancer care.
This review reveals 54 oral assessment instruments practi-
tioners can choose from.
The appropriateness of the chosen instrument is vital to the
meaningfulness of the information obtained.2 Ensuring an instru-
ment is fit for purpose needs to be judged by the appropriateness
of the items on the scale, augmented by a critical review of the
evidence in support of the instrument.86 Bowling87 suggests that
when selecting a measurement scale, researchers should ensure
that it is relevant to the target population and appropriate for
the research question and satisfies the principles of measurement,
including reliability and validity. Similarly, for practitioners,
there is a need to find a validated, reliable, and useful scoring
instrument that is best suited to daily nursing practice.88 This
review revealed 1 instrument to be currently recommended in
our mouth care guidelines, based on asking a series of ques-
tions that are addressed in the discussion that follows:
1. What is the purpose of oral assessment?
2. Who is being assessed?
3. What clinical outcomes are measured, and how are they
scored?
4. What is the quality of the instrument?
5. How easy-to-use is the instrument?
This review confirms others’ suggestion that there are distinct
categories of scoring systems.6,89 There are those that use 4 or 5
grades to score the general appearance of the oral cavity (simple
scales)35Y38,40Y44,49,53,56,63,68,73,75,77,81Y83 and those that score a
number of different parameters individually (multicomponent
scales).30Y34,39,45Y48,50Y52,54,55,57Y62,64Y67,69Y72,74,76,78Y80 Sev-
eral within the second category are instruments specifically de-
veloped as nursing management and clinical tools. The range
and variety of instruments available for use in clinical trials
verify the view that there remains no universally accepted,
validated scoring system.6,89,90 The purpose for which the
instrument will be used compared with the purpose for which
the instrument was designed is yet a further consideration. The
rationale for assessment has clearly influenced the evolution of
these 2 groups of scales. However, although the scales used as
clinical tools are described as encompassing patient-reported
outcomes, there is still some criticism that they fail to capture
the patient experience. They are thought to exclude psycho-
social morbidity and quality of life that may be significant in
patient choice when interventions have similar effects on mu-
cositis.91,92 The recent development of new patient-generated
instruments is therefore very timely.54,61,71 Despite this
criticism, whether for clinical or research purposes, this review
assessed only the OAG39,48,51 as a suitable instrument to be
used in the field of children’s and young people’s cancer care.
In recommending this instrument, previous validation data, as
well as perceived ease of use with children, were considered
highly.
There was a predominance of instruments developed
and tested for use in cancer patients older than 18
years.31Y35,37,38,40,45,47,48,53Y57,59,63,66Y71,73Y78 There are
Cancer NursingTM, Vol. 33, No. 4, 2010 n E5
 Table 1 & Components Covered in Identified Oral Assessment Tools
Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
30
Aquino et al ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component graded
0Y2. Compound score
used to grade mucositis
(0Y16)
Beck31 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component graded
1Y4
Compound score (15Y64)
Includes patient-reported

E6 n Cancer NursingTM, Vol. 33, No. 4, 2010

outcomes
Bentzen et al ¾ ¾ ¾ Each sign (within
(Dische)32 component) graded 0Y3
or 0Y5. Grade 1 not
used in mucus
membrane component.
No compound score
Bolwell et al ¾ ¾ ¾ Severity graded 0Y1-m
(mOMAS)33 OMAS score calculated
from sum of ulceration
and erythema scores
Bruya and ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component (and
Madeira34 sub-component) graded
1Y3
No compound score
Byfield et al35 ¾ ¾ ¾ Mucositis scale
Components used to grade
mucositis 1Y4
Developed for research
No compound score
Turhal et al ¾ ¾ ¾ CALGB’s expanded
(CALGB)36 common toxicity
criteria. Signs used to
grade mucositis 0Y4
Carl and ¾ ¾ ¾ ¾ Components used to grade
Emrich37 mucositis (0Y3)
according to varying

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
degrees of erythema,
ulceration, pain, and
ability to eat
continues

Gibson et al
 Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
38
Chapko et al ¾ Part of behavioral measure
of mouth pain, nausea,
and well-being
No compound score
Chen et al39 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Assessing usability of Eilers’
OAG with children
Each component graded 1Y3
Compound score (8Y24)
Cox and Pajak40 ¾ Part of RTOG/EORTC
(RTOG/ late radiation scoring
EORTC) scheme

Oral Assessment Instruments

Each organ tissue included
scored from 0Y4
Used for clinical trials
No compound score
CTCAE v.241 ¾ Signs used to grade
(radiotherapy) mucositis (0Y4)
No compound score
CTCAE v.241 ¾ ¾ ¾ ¾ Signs used to grade
(chemotherapy) mucositis (0Y4)
No compound score
CTCAE v342 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Part of a broader toxicity
scale. Each compound
graded 1Y5
No compound score
CTCAE v443 ¾ ¾ Signs used to grade
mucositis (0Y5).
No compound score
Damon et al44 ¾ ¾ ¾ ¾ ¾ Signs used to grade
mucositis (0Y4)
Dibble et al45 ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component graded
(MacDibbs) 0Y3
Compound score (0Y21)
Includes patient-reported
outcomes
Donnelly et al46 ¾ ¾ ¾ Mucositis scale
Compound scale (0Y15)
Dudjak47 ¾ ¾ ¾ ¾ ¾ ¾ ¾ Adaptation of earlier tools
Each component graded 1Y4
Compound score (7Y28)

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Reports difficulties in
monitoring change
Eilers et al ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component graded 1Y3

Cancer NursingTM, Vol. 33, No. 4, 2010

(OAG)48 Compound score (8Y24)

E7 n
continues
 Table 1 & Components Covered in Identified Oral Assessment Tools, continued
Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
Developed for research use
and clinical practice
Ferretti et al49 ¾ ¾ ¾ Signs used to grade
mucositis (0Y3)
Gandemer et al50 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Anatomical sites graded
0Y3, functional signs
graded 0Y2, pain VAS
0Y100. Interim

E8 n Cancer NursingTM, Vol. 33, No. 4, 2010

compound score. Used
alongside WHO grading
Gibson et al51 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Assessing usability of Eilers’
OAG with children
Each component graded 1Y3
Compound score (8Y24)
Harris52 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Tool developed to assess
pain. Esophagus,
stomach, gut, and anus
also included in tool.
Location scores graded
0Y10, ability to swallow/
eat and talk graded
‘‘able’’/with difficulty or
‘‘unable.’’ Response to
intervention (graded
0Y4). Developed for
clinical practice
No compound score
Hickey et al53 ¾ ¾ ¾ ¾ Signs used to grade
mucositis (grade 1Y3)
No compound score
Kushner et al ¾ ¾ ¾ ¾ ¾ 10 VAS scales used by
(PROMS)54 patient to grade
mucositis. Average score
then calculated
Kushner et al ¾ ¾ ¾ ¾ ¾ ¾ Ordinal grades of severity

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(mOMAS)54 replaced with 100-mm
VAS scales for erythema
and ulceration at each
site. Total erythema and

Gibson et al
continues
 Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
total oral ulceration also
graded using VAS
Lievens et al55 ¾ ¾ Part of broader toxicity scale
Mucositis graded 0Y6,
dysphagia graded 0Y4
No compound score
Lindquist et al56 ¾ ¾ ¾ ¾ ¾ ¾ ¾ Signs used to grade
mucositis (0Y3)
Maciejewski et al57 ¾ ¾ Each sign (within component)
(Dische system) graded 0Y3 or 0Y4
Compound score (0Y24)

Oral Assessment Instruments

McGuire et al ¾ ¾ ¾ ¾ ¾ ¾ 9 Anatomical sites. Each
(1993)58 component graded 0Y3.
(DATOE) Extent of ulceration (cm2)/
erythema (%) graded 0Y4
McGuire et al ¾ ¾ ¾ 20 Items assessed at 9
(2002)59 anatomical sites. Each
component graded 0Y3.
Ulceration/
pseudomembrane graded
by size. Compound score.
Requires use of an OMI
grading rules handout
NIH60 ¾ ¾ ¾ ¾ ¾ ¾ ¾ Part of broader toxicity scale
Each component graded 0Y4
No compound score
Developed for research use
Öhrn et al61 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Patient-reported outcomes
(VAS)
Incorporates OMI
No compound score
Passos and ¾ ¾ ¾ ¾ ¾ Each component graded from
Brand62 1Y3 (normal to severe)
Compound score (8Y24)
Pitten et al63 ¾ ¾ ¾ Signs used to grade
mucositis (0Y4)
Potting et al64 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Structured according to signs
rather than components
Each component graded
0Y3

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Compound score (0Y18)
Includes patient-reported
outcomes

Cancer NursingTM, Vol. 33, No. 4, 2010

n
continues

E9
 Table 1 & Components Covered in Identified Oral Assessment Tools, continued
Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
65
Raether et al ¾ ¾ ¾ ¾ Percentage of ulceration
Compound score
Schubert et al ¾ ¾ ¾ ¾ Structured according to signs
(OMI)66 rather than components
Includes patients based
assessment
Compound score
(maximum 34)
Kolbinson et al ¾ ¾ ¾ ¾ ¾ ¾ ¾ Developed as research tool

E10 n Cancer NursingTM, Vol. 33, No. 4, 2010

(OMI/ Each component graded
OMRS)67 from 1Y3 (normal to
severe). Compound score
Seto et al68 ¾ ¾ ¾ Oral debris categorized as
‘‘excellent,’’ ‘‘good,’’
‘‘fair,’’ or ‘‘poor’’
Signs used to grade
mucositis (grade IYIV)
No compound score
Sonis et al69 ¾ ¾ ¾ ¾ ¾ ¾ Each component graded.
Subjective components
recorded separately.
Compound scoreVweighted
mean mucositis score
calculated
Scoring complex for
clinical practice
Spijkervet et al70 ¾ Components graded 0Y4
Mucositis score calculated
according to signs/size
of ulcerations
Developed as a research tool
Use of ruler for measuring size of
ulcers reduces tolerability and
use in clinical practice
No compound score

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Stiff et al71 ¾ ¾ ¾ Oral Mucositis Daily
QuestionnaireVpatient-
reported questionnaire;
continues

Gibson et al
 Hard/
Mucous Soft Swallow/ Self- Dry
Lips Tongue Membrane Gingiva Teeth Palate Saliva Voice Dysphagia Taste Diet care Pain Mouth Comments
6 questions, 3 scored
0Y10, 3 scored 0Y4.
Used in conjunction with
WHO, RTOG, and
WCCNR within RCT.
No compound score
Sung et al72 ¾ ¾ ¾ ¾ ¾ ¾ Assessing usability of Sonis’
OMAS with children
Each component graded
Compound scoreV
weighted mean mucositis

Oral Assessment Instruments

score calculated
Scoring complex for
clinical practice
Tanner et al73 ¾ ¾ ¾ Signs used to grade mucositis
(grade 0Y3). Scale also
includes delay in
chemotherapy/radiotherapy
Tardieu et al74 ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Each component graded 0Y3
Compound score (daily index
of mucositis) (0Y48)V
used to grade mouth status
Van der Schueren ¾ Signs used to grade mucositis
et al75 (graded level IYIV)
No compound score
Van Drimmelen ¾ ¾ ¾ ¾ ¾ ¾ Each component graded
and Rollins76 from 1Y3 (normal to
worst condition)
Compound score 7Y21
WCCNR77 ¾ ¾ ¾ ¾ Signs used to grade mucositis
(graded 1Y3)
No compound score
Staging system from
‘‘healthy mouth’’ to
‘‘stage 3’’
Developed for research use
and clinical practice for
evaluating management
of stomatitis
(Olson et al)78 ¾ ¾ Compound score.

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(WCCNR, Bleeding and erythema
2004) also scored. Updated

Cancer NursingTM, Vol. 33, No. 4, 2010

WCCNR pain/dry

n
mouth scores removed
continues

E11
 Mucositis Index; OMRS, Oral Mucosa Rating Scale; PROMS, Patient-Reported Oral Mucositis Symptom; RTOG, Radiation Therapy Oncology Group; WCCNR, Western Consortium for Cancer Nursing Research;
Abbreviations: CALGB, Cancer and Leukaemia Group B; EORTC, European Organisation for Research and Treatment of Cancer; OAG, Oral Assessment Guide; OMAS, Oral Mucositis Assessment Scale; OMI, Oral
inherent problems with instruments being used in children,

size of ulcers. Compound

Each component graded 0Y2

Components used to grade

0Y3. Scale incorporates
(0Y21)Vused to grade

mucositis (grade IYIV)

Each component graded
which have been developed for a different population that has
little in common with those being studied. For example, the

No compound score
Used to inform oral
Comments

hygiene regimen
instrument items may not be sufficiently sensitive to

Compound score

mouth status

score (0Y21)
discriminate important differences between groups or detect
changes over time.93 If changes are expected to be very small,
an instrument must be sensitive to detect changes. In
addition, there is value in grounding measurement in the
experience of knowledgeable informants, a process that might
influence sensitivity. Of those studies detailing use and testing of
Mouth
Dry

instruments specifically with children,39,51,72 all were based on

instruments originally developed with adults.48,69 This finding
Pain

might suggest a shared conceptual definition of the variables to

¾

¾
be assessed,94 based on what is important, relevant, and
discriminating in terms of oral mucositis. For example, content
Self-
care

specialists in pediatric oncology agreed that the 8 parameters of

the OAG were valid domains for scoring oral problems.51
Diet

Similarly, Sung and colleagues72 found the OMAS to be valid

¾

in children. However, in addition to content, appropriateness

Taste

and acceptability must also be judged in relation to the

population to be assessed. For instance, modifications to the
OAG were considered necessary to reflect the specific needs of
Dysphagia
Swallow/

children, where the order of the items was altered, and placing
¾

voice last, as opposed to first, reflecting the more gradual

approach to assessment in children that allows time in the
procedure to gain a child’s trust.51 Appropriateness of the
Voice

OMAS is not commented on by Sung and colleagues,72 neither

Table 1 & Components Covered in Identified Oral Assessment Tools, continued

is there sufficient detail of the procedure on which a judgment

can be made. Thus, the final decision was to recommend the
Saliva

OAG.51
¾

This review also highlighted that many instruments combine

objective signs of mucositis (such as erythema and ulceration)
Hard/

Palate
Soft

with subjective symptomatic outcomes (such as pain and

swallowing) (Table 1). Absolute objectivity is thought not pos-
Teeth

sible in oral assessment, where human judgment and interob-

¾

server variability remain a significant factor in the accuracy of

assessment.23,90,95,96 Even with this potential for error, however,
Gingiva

the combination of objective and subjective items in an in-

¾

strument is thought to be problematic as it may result in un-

derscoring and underreporting of symptomatic outcome
VAS, visual analogue scale; WHO, World Health Organization.

measures.92 On the other hand, the omission of oral symptoms

Membrane
Mucous

may limit the value of the assessment, leading to false con-

¾

clusions, and may potentially influence an incorrect clinical

decision.97 Likewise, there is a danger in inappropriate scoring,
leading to symptoms being underrated or exaggerated where
Tongue

there is a discrepancy between the clinical meaning of results

¾

obtained by a total scale score and of results obtained by in-

dividual scoring.98 Responding to some of these criticisms,
Lips

Gibson and others51 removed all mention of pain from the

¾

OAG, an entirely subjective experience, leaving only parameters

described as objective, thus increasing the potential for the
instrument to be more reliable. Recognizing that the nature and
Weisdorf et al80
79

severity of oral symptoms are also legitimate outcome concerns

Walsh et al

WHO81Y83

that may necessitate the addition of further specific assessment

instruments, Gibson and colleagues51 suggest the inclusion of
pain scales and other symptom-focused instruments when as-
sessing the mouth of children and young people. The inclusion

E12 n Cancer NursingTM, Vol. 33, No. 4, 2010 Gibson et al

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 2 & Assessment of Studies, Using Adapted Diagnostic Studies Checklist,15 Reporting Validity/Reliability Testing of Oral Assessment Tools
Chen Dibble Donnelly Eilers Gibson Kushner McGuire Olson Potting Sonis Spijkervet Stiff Sung Tardieu WCCNR
et al39 et al45 et al46 et al48 et al51 et al54 et al59 et al78 et al64 et al69 et al70 et al71 et al72 et al74 et al77
(2004) (1996) (1992) (1988) (2006) (2008) (2002) (2004) (2005) (1999) (1988) (2006) (2006) (1996) (1991)
Participants
Was selection Y N Y Y V N U U Y Y U Y N Y U
bias avoided?
Did the study Y Y Y Y V Y Y Y N Y Y Y Y Y Y
include an

Oral Assessment Instruments

appropriate
spectrum of
participants?
Reliability
Interrater Y Y N Y N N Y Y Y Y Y N Y Y N
measured?
Was the U U V Y V V Y Y Y Y Y V Y Y U
duration
between
assessments
suitable so as
not to have
allowed a true
change in oral
health status?
Intrarater N N N N N N Y N N N N Y N Y N
measured?
Was the V V V V V V U V V V V Y V U V
duration
between
assessments
suitable so as
not to have
allowed a true
change in oral
health status?
Validity
Was face N N N N Y Y Y N Y Y Y N N N N
validity
reported?

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Do you feel the Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
tool appears to

Cancer NursingTM, Vol. 33, No. 4, 2010

measure the

n
continues

E13
 Table 2 & Assessment of Studies, Using Adapted Diagnostic Studies Checklist,15 Reporting Validity/Reliability Testing of Oral Assessment Tools, continued
Chen Dibble Donnelly Eilers Gibson Kushner McGuire Olson Potting Sonis Spijkervet Stiff Sung Tardieu WCCNR
et al39 et al45 et al46 et al48 et al51 et al54 et al59 et al78 et al64 et al69 et al70 et al71 et al72 et al74 et al77
(2004) (1996) (1992) (1988) (2006) (2008) (2002) (2004) (2005) (1999) (1988) (2006) (2006) (1996) (1991)
condition of Y
the mouth?
Was content Y Y N Y Y N Y N Y Y N N N N Y
validity
reported?
Were appropriate Y Y V Y Y V Y V Y Y V V V V Y
experts
consulted in
the

E14 n Cancer NursingTM, Vol. 33, No. 4, 2010

development
of the tool and/
or a rigorous
evaluation of
the literature?
Does the tool Y Y V Y Y V Y V Y Y V V V V Y
address all the
attributes of
the concept
under
investigation?
Does the tool N N V N N V N V N N V V V V N
include any
irrelevant
items?
Was criterion N N N N N Y Y Ya N N Y Y N N Y
validity
reported?
Was the test V V V V V Y Y Ya V V Y Y V V Y
compared
with a valid
reference
standard?
Were the test V V V V V Y U U V V U N V V U
and reference
standards

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
measured
independently
(blind) of
each other?

Gibson et al
 Chen Dibble Donnelly Eilers Gibson Kushner McGuire Olson Potting Sonis Spijkervet Stiff Sung Tardieu WCCNR
et al39 et al45 et al46 et al48 et al51 et al54 et al59 et al78 et al64 et al69 et al70 et al71 et al72 et al74 et al77
(2004) (1996) (1992) (1988) (2006) (2008) (2002) (2004) (2005) (1999) (1988) (2006) (2006) (1996) (1991)
Was the choice V V V V V Y U U V V Y V V V U
of patients for
assessment by
the reference
standard
independent
of the test’s
results?
Was the V V V V V U U U V V U V V V Y
reference
standard

Oral Assessment Instruments

measured
before any
interventions
were started
with
knowledge of
test results?
Was construct N N N N N Y Y N N N Y N Y N N
validity
reported?
Do you feel there V V V V V Y Y V V U Y V Y V V
is good
justification
for the
theoretical
construct
used?
Overall opinion
Would you use Y N N Y N Y N N N N N U N Y N
this tool in
everyday
clinical
practice with
adults?
Would you use Y N N Y Y N N N N N N U N N N
this tool in
everyday
clinical
practice with

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
children?
Would you use Y Y N Y N N Y N Y N N Y N N N

Cancer NursingTM, Vol. 33, No. 4, 2010

this tool in

n
continues

E15
 of a composite score, as opposed to scoring individual items was

WCCNR
Table 2 & Assessment of Studies, Using Adapted Diagnostic Studies Checklist,15 Reporting Validity/Reliability Testing of Oral Assessment Tools, continued

(1991)
et al77
also considered by Gibson and colleagues.51 Although the final

N
decision was to continue to refer to a total score, its inter-
pretation into clinical practice is based on an individual item
Tardieu

(1996)
et al74
score, where interventions are guided by a treatment algorithm

N
focused on individual items contained in the instrument.99
There was little evidence in this review regarding the
validation of instruments, with only 15 of the identified 54
(2006)
et al72
Sung

N
instruments (28%) reporting psychometric testing to assess the
properties of validity or reliability (Table 2). As reliability will
vary from sample to sample, an instrument’s reliability should
(2006)
et al71
Stiff

be reestimated for each study. In contrast, validity is a relatively

N

stable property as long as the instrument is used appropriately

to derive the type of data for which it was developed. Use of an
Spijkervet

(1988)

unreliable or invalid instrument may invalidate the testing of

et al70

research hypotheses and, in clinical care, may adversely in-

fluence the nursing diagnosis and the care prescribed. While
there exist several options for the valid measurement of mu-
(1999)
et al69
Sonis

cositis in adults undergoing cancer therapies, this is not the

N

same for children. However, this review revealed some recent

evidence of activity seeking to remedy this omission.39,51,72,100
The validity of the OAG has been described in 2 studies.39,51
(2005)
Potting
et al64

Assessment of interrater agreement between nurses and dentists

has been shown to be good across all 8 categories (. values
ranged from 0.77 to 1.00) when assessing chemotherapy-
(2004)
et al78

induced oral complications in children.39 A judgment quanti-

Olson

fication process with professionals in pediatric oncology

confirms the OAG offers structure, rigor, and clear guidance
when assessing the mouths of children and young people.51
McGuire

(2002)
et al59

As well as the quality of the instrument, its sensitivity, validity,

Abbreviations: N, no; U, unclear; WCCNR, Western Consortium for Cancer Nursing Research; Y, yes.

and reliability, it should also be relatively easy to use in clinical

practice. The items need to be understood by those using the
Kushner

(2008)
et al54

instrument and not be too demanding in terms of skills and time

N

to administer. A further consideration in relation to children and

young people is the need for an instrument to be noninvasive.
Children undergoing treatment for cancer experience many
Gibson

(2006)
et al51

invasive procedures; to increase the possibility of acceptance oral

Y

assessment, as yet another procedure to undergo, it is important

that close observation is sufficient to make an accurate assess-
(1988)
et al48

ment.101 A number of instruments reviewed did not fulfill these

Eilers

criteria (Table 1). This review revealed only 1 instrument to be

useful in clinical practice in the field of children’s and young
people’s cancer care.51 This instrument has been described as
Donnelly

(1992)
et al46

clinically useful for assessing oral cavity status, determining

changes, and guiding nursing interventions in pediatric cancer
care.39,51,101 It has been consistently judged to be user-friendly
(2004) (1996)
Chen Dibble
et al39 et al45

and appropriate for everyday clinical practice with both adults

N

and children, as well as a useful research tool.

Radiotherapy patients only.
Y

n Conclusion and Further Research

Would you use
with adults?

this tool in

children?

This review has accomplished 2 goals. First, it has systemati-

research

research

cally retrieved and assessed the quality of the range of oral

with

assessment instruments available.

Second, it has identified and recommended to practi-
tioners through the production of evidence-based guidelines
a

E16 n Cancer NursingTM, Vol. 33, No. 4, 2010 Gibson et al

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
an instrument, the OAG, and further adaptations of this in-
strument, to be currently the most appropriate and clinically
useful instrument for use in the field of children’s and young
people’s cancer care. There remains, however, one further
challenge to researchers, and that is to validate a universally
agreed-on oral assessment instrument. The main reason is
inextricably linked to the evaluation of outcomes in clinical trials.
Recent systematic reviews have looked at the prevention and
treatment of oral mucositis in patients undergoing treatment for
cancer.102,103 Between them, these reviews included more than
100 RCTs reporting on a variety of mucositis measures.
Measures included improvement or eradication of mucositis,
days to healing, or severity of mucositis. The indices used to
assess mucositis also varied; some were unspecified, but most
indices were described (typically a 0- to 4-point scale) or
referenced. The most frequently used published indices were
those of the WHO,81Y83 European Organization for Research
and Treatment of Cancer, and Radiation Therapy Oncology
Group.40 More than 30 RCTs were excluded from the reviews
because of the data on mucositis being in an unsuitable form for
comparison with other trials. Given the impact oral mucositis can
have on cancer patients’ quality of life, it is imperative that the
results of all clinical trials are utilized in practice. To facilitate this,
consideration needs to be given to the adoption of standard clinical
outcome measures. In addition, the development of patient-based
outcome measures that, as a minimum, should include the
reduction of oral pain should also be encouraged.102,103
At a time of increased scientific activity around the de-
velopment of new agents to prevent oral mucositis, there is a
greater need for reliable and validated oral assessment instru-
ments. Between 2004 and 2008, this review revealed the
addition of 28 oral assessment instruments: 14 were revisions of
previous instruments30,32,33,39,41Y43,51,54,58,59,72,78 and 14 were
new instruments.36,37,44,49,50,52,54,56,63Y65,71,73,80 Where revi-
sions had been made, the decisions underpinning these
changes were not always clear, and for many of the new
instruments, their development, with respect to other instru-
ments already available, was not always justified. Only 8 of
these instruments had been validated.39,51,54,59,64,71,72,78 The
need for the employment of a validated and reliable instru-
ment in future clinic trials cannot be understated. We would
still seem to be some way from having a universally accepted,
validated, and reliable scoring scheme, in particular for use
with children.
ACKNOWLEDGMENTS
The authors thank all members of the CCLG/PONF Mouth
Care Group for their contributions to the review process and
commenting on the manuscript: Tim Eden, Jan Clarkson,
Tasneem Khalid, Anna Kyriazidou, Barry Pizer, and Helen
Worthington.
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