Grade
WHOa
NCI-CTCb
Bearman
Grade 0
No oral abnormalities
No oral abnormalities
No oral abnormalities
Grade 1
Oral soreness +/− erythema without ulceration; able to tolerate regular diet
Erythema
Pain and/or ulceration not requiring a continuous IV narcotic drug
Grade 2
Oral soreness with erythema and ulcerations; able to tolerate solid food
Patchy ulcerations or pseudomembranes
Pain and/or ulceration requiring a continuous IV narcotic drug (morphine drip)
Grade 3
Oral soreness with erythema and ulcerations; able to tolerate liquids only
Confluent ulcerations or pseudomembranes; bleeding with minor trauma
Severe ulceration and/or mucositis requiring preventative intubation; or resulting in documented aspiration pneumonia with or without intubation
Grade 4
Oral soreness with erythema and ulcerations; unable to tolerate anything by mouth
Tissue necrosis; significant spontaneous bleeding; life-threatening consequences
Death
Grade 5
Death
Table 20.2
Management of oral complications
Symptom | Severity | Treatment |
|---|---|---|
Pain | Mild | Use of bland oral rinses to maintain moisture Normal saline swish and spit every 2 h Sodium bicarbonate solution every 2 h Sodium chloride rinses Sponge swab Ice chipsUse of sialagogues Artificial saliva Sugarless hard candies or sugarless gum Pilocarpine (Salagen®) 5–10 mg po TID Cevimeline (Evoxac®)30 mg po TID Bethanechol 25 mg po TID Topical fluoride treatments Biotene® mouthwash or toothpaste Reduce oral challenges such as converting all medications to IV formula, providing IV fluid and/or parenteral nutrition |
Moderate | Topical analgesia Compounded mouthwashes (Maalox®: Benadryl elixir: Viscous Lidocaine 1:1:1) 10–15 mL swish and spit every hour PRN Benzocaine gel apply topically to oral lesions QID PRN Doxepin (Sinequan®, Adapin®) 5 mg/mL, 5 mL po held in the mouth for 5 min PRN Systemic opiates Scheduled opiate administration | |
Severe | Parenteral narcotics Use of narcotic patches and IV administration Patient-controlled analgesia | |
Xerostomia and hyposalivation | Use of bland oral rinses to maintain moisture Normal saline swish and spit PRN Sodium bicarbonate solution every 2 h Sponge swab Half-strength hydrogen peroxide swish and spit PRN Use of sialagogues Artificial saliva Sugarless hard candies or sugarless gum Pilocarpine (Salogen®) 5–10 mg po TID Cevimeline (Evoxac®) 30 mg po TID Bethanechol 25 mg po TID Topical fluoride treatments Biotene® mouthwash or toothpaste Caphosol® swish and spit 4–10 times daily PRN | |
Thick secretions | Use mucolytic drying agents Scopolamine patch (Transderm Scop®) TD behind ear apply every 72 h Dimenhydrinate (Dramamine®) 25–50 mg po every 4 h PRN Diphenhydramine 25–50 mg po or 12.5–25 mg IV every 6 h PRN Lorazepam 0.5–1 mg po/IV every 6 h PRN (gag reflex) Utilize suction to alleviate secretions Utilize blow by humidified air | |
Emesis | Antiemetics scheduled around the clock | |
Bleeding | Transfuse to maintain platelets > 20,000 for mild gingival bleeding Transfuse to maintain platelets > 50,000 for severe gingival bleeding | |
Airway protection | Utilize blow-by humidified air Short course of IV steroids ENT consult for preemptive intubation for airway protection
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