This study retrospectively examined the clinical data of 65 patients with HNC who underwent RT or CRT at our Hospital between June 2018 and May 2020. Among the 65 tumors, 64 were histologically confirmed as squamous cell carcinomas, and one malignant lymphoma.
All patients received RT involving three-dimensional conformal RT (3D-CRT) (46 patients) or intensity-modulated RT (IMRT) (19 patients). The overall therapeutic irradiation dose was 30–70 Gy (median, 50 Gy). The purpose of RT was post-operative irradiation. Two patients had their planned RT doses reduced and interrupted (30 Gy and 54 Gy) due to deterioration of their nutritional status. The original dose for a 30 Gy patient was 50 Gy, and the original dose for a 54 Gy patient was 60 Gy. RT was performed once per day (2 Gy) five times a week. In addition, 63 patients received concurrent chemotherapy; the regimens included either cisplatin (CDDP; 30 mg/m2/w), tegafur-gimeracil-oteracil-potassium (TS-1®) (80 mg/m2), or cetuximab (400 mg/m2/w and 250 mg/m2/w) (Table 2).
Prior to the start of RT, an oral care team comprising an oral surgeon and dental hygienist examined the oral cavity and administered oral hygiene care for patients with HNC. Simultaneously, patients were oriented regarding OM management, including instructions regarding tooth brushing, mouth washing, oral moisturizing, nutrition, and using Episil® during treatment.
During the treatment, daily assessment of OM severity was conducted regarding functional disorders, symptomatic aspects, and clinical examination according to Common terminology criteria for adverse events (CTCAE) version 4.0. OM severity was graded as follows: grade 1, asymptomatic or mild symptoms, intervention not indicated; grade 2, moderate pain, not interfering with oral intake, diet modification indicated; grade 3, severe pain, interfering with oral intake; grade 4, life-threatening consequences, urgent intervention indicated; grade 5, death.
When OM was first observed and patients started to experience pain, we prescribed our original mouthwash containing sodium gualenate hydrate, sodium bicarbonate, and 0.2% lidocaine (Xylocaine), which was gargled 6–8 times a day. We repeated the discussion regarding Episil® use, and left the decision of receiving it to the patients. Episil® was administered by one dentist (Y.K.), and patients were instructed to use it three times per day, at least 5–10 min before a meal. Patients experiencing difficulties using Episil® in this manner prompted the dental hygienist to explain methods of easier administration, as described earlier in the manuscript.
We assessed pain relief after RT according to the WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain . To minimize the impact of confounding factors, we confirmed the timing of all pain medications, including opioids, and ensured the presence of at least a 2-h interval before starting Episil®. The pain-relieving effect of Episil® was confirmed by one dentist (Y.K.) within 6 h of its use in an interview with each patient by recording the patients’ impressions of its use. Pain in the oral mucosa was assessed by a dentist (Y.K.) and noted in the medical records.
All statistical analyses were performed using the IBM SPSS version 22.0 (IBM, Armonk, NY, USA). The measurement data were expressed as the median, maximum (max), and minimum (min) values and were analyzed using the Mann–Whitney U test or Pearson's chi-square test. Statistical significance was set at P<0.05.