Table 5.
Evidence summary on managing radiotherapy-induced oral mucositis in patients with head and neck cancer.
| Evidence aspect | Evidence item | Evidence level | Recommendation level |
|---|---|---|---|
| Multidisciplinary management | 1. The OM treatment should be performed by a multidisciplinary team, including oncologists, stomatologists, dietitians, nurses, pharmacists, and radiotherapy technicians. Nurses play a key role in the care of oral mucositis.13,16 | Level 5 | A |
| Oral assessment | 2. Clinical professionals assessing patients should receive regular specialized training (e.g., on the use of assessment tools).17,18 | Level 5 | A |
| 3. Oral assessment tools: The most used clinical grading criteria for oral mucositis include the WHO, RTOG determined the acute radiation morbidity scoring criteria, OAG, and NCI/CTC.15,17 | Level 5 | A | |
| 4. RTOM risk assessment based on the patient and treatment-related factors before radiotherapy, scoring into low, moderate, and high risk.15,16 | Level 1 | B | |
| 5. Patients should undergo regular oral assessment examinations before, during and after radiotherapy to dynamically adjust interventions.16,17 | Level 2 | A | |
| 6. All patients at risk for OM should have a baseline oral assessment before receiving their first radiotherapy. For patients with moderate or high risk of OM, a dentist could assist in the assessment and preventive treatment. It is recommended to check every 2–3 days.16,17 | Level 5 | A | |
| 7. Patients undergoing radiotherapy should continue to receive continuous oral care for up to one month after the end of radiotherapy. Oral evaluations should be conducted every two weeks.16,17 | Level 5 | A | |
| 8. All patients undergoing radiotherapy should be encouraged to evaluate their mouth and report any changes in oral symptoms they notice or experience to health care professionals.16,18 | Level 1 | A | |
| 9. Health care professionals should guide outpatients with OM to use a self-assessment instrument at home during every clinical visit.17 | Level 5 | A | |
| Basic oral care | 10. Good oral hygiene can help to prevent and alleviate oral mucositis. Educate patient to brush the teeth with a soft-bristled toothbrush and fluoride toothpaste after every meal and before going to bed, and change toothbrush monthly or more frequently, depending on the patient's risk of infection.14,17 | Level 5 | A |
| 11. Patients wearing dentures should be guided to properly care for the dentures and reduce the stimulation of oral mucosa. Patients with dental caries should strengthen the cleaning of residual roots.14 | Level 5 | A | |
| 12. Educate patient to avoid food and drink that might aggravate mucosal damage, pain, or discomfort (e.g., overheated, over-acidic, spicy, and coarse food), and quit smoking and drinking.15,16 | Level 5 | A | |
| 13. Patients are encouraged to do daily mouth opening, cheek drums, teeth tapping, and other oral function exercises to increase the gas exchange between the oral mucosa and the outside, destroy the living environment of anaerobic bacteria, and prevent secondary infections.15 | Level 3 | B | |
| 14. Mouthwash: Choose the right mouthwash based on the patient's oral pH. Clean the mouth with an alcohol-free saline mouthwash. Gargle first, then drum gargle. Use 15 mL/time, 1 min/time, 4 times/day. Avoid water and food for 30 min after gargling. Patients with ulcers or other problems should gargle frequently (every 2 h while awake).11,12,14 | Level 3 | A | |
| Pain management | 15. The pain score reflects changes in the patient's mouth and should be part of the oral evaluation.17 | Level 5 | A |
| 16. Systemic use of strong opioids such as morphine or fentanyl is recommended when severe pain is present.15 | Level 3 | A | |
| 17. Sulfoaluminium (local or systemic) is not recommended for oral mucositis-associated pain prevention in patients undergoing radiotherapy for head and neck cancer.11 | Level 2 | B | |
| Nutritional support | 18. Nutritional risk assessment should be carried out dynamically in patients with cancer.14 | Level 5 | A |
| 19. Nutritional intervention should be carried out for patients at risk of malnutrition according to the five-step nutritional intervention model recommended by the professional committee of tumor nutrition and supportive therapy of the Chinese anti-cancer Association.14 | Level 5 | B | |
| 20. Oral nutritional supplements should be given to those able to eat. Enteral nutrition supplements (e.g., by tube feeding) can be given to patients unable to chew or swallow. Parenteral nutrition should be adjusted to achieve the target requirements.14 | Level 5 | A | |
| Application of honey or propolis | 21. It is recommended that honey or propolis be used to prevent or reduce the incidence and severity of RTOM in patients undergoing radiotherapy for head and neck cancer.14,19,20 | Level 2 | B |
| 22. Nurses can guide patients 15–20 mL/time honey before the start of each radiotherapy session, and 15 min and 6 h after it ends. Honey should be taken 3 times/day for ≥ 7 days, keeping it in the mouth for 5 min to ensure full contact with the oral mucosa.14 | Level 5 | B |
NCI/CTC, National Cancer Institute/Common Terminology Criteria; OAG, Oral assessment guidelines; OM, oral mucositis; RTOG, Radiation Therapy Oncology Group; RTOM, radiotherapy-induced oral mucositis; WHO, World Health Organization.