Effect of the Oral Care Intervention Protocol (OCIP) on the Oral Health Scores of Head and Neck Cancer Patients Receiving Radiation/Chemoradiation

Effect of the Oral Care Intervention Protocol (OCIP) on the Oral Health Scores of Head and Neck Cancer Patients Receiving Radiation/Chemoradiation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of the Oral Care Intervention Protocol (OCIP) on the Oral Health Scores of Head and Neck Cancer Patients Receiving Radiation/Chemoradiation Radhika R Pai, Sourjya Banerjee, Linu Sara George, Anice George, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4534806/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Head and neck cancer patients receiving chemotherapy and radiation therapy may experience a notable and frequently sudden decline in their oral health. These alterations include oral mucositis that develops during and shortly after treatment, candida infections, trouble speaking, difficulty eating, bleeding gums, and tissue fibrosis. Materials and Methods The study aimed to determine the effectiveness of oral care protocol intervention on oral health and oral complications. These patients were observed every week for up to 6 weeks until the completion of radiation therapy/chemoradiation. An experimental design using a Randomized Controlled Trial was adopted for the study. After obtaining the informed consent, the data were collected from 80 head and neck cancer patients. Results The majority, i.e., 51.2%, were in the experimental group, and 52.5% were in the age group of 56 years and above. Most patients were males, 92.5% in the experimental group and 87.5% in the control group. A maximum number of the patients, i.e., 42.5% in the experimental group and 32.5% in the control group, were diagnosed to have tongue cancer. Regarding the treatment details of the participants, most of the participants, i.e., 57.5% in the experimental group and 67.5% in the control group, received chemoradiation as the treatment plan. Among all the oral complications, the median days to develop mucositis (p = .015), taste loss (p = .028), swallowing difficulty (p = .004), infection (p = .017), xerostomia (p = .004) and bleeding gums (p = .025) were statistically significant in comparison with control, indicating that the intervention was effective. As treatment progressed, the severity of these structural changes and functional activities increased in both groups. Over the weeks, the severity of the oral problems increased in both groups (p < .001). Conclusion Compared to the standard of oral care, oral care intervention improved oral health among cancer patients receiving radiation therapy/chemoradiation. The findings of this study can also contribute to justifying the evidence for using an oral care protocol for head and neck cancer patients. Figures Figure 1 Figure 2 INTRODUCTION Cancer patients receiving chemotherapy and head and neck radiation therapy may experience a notable sudden decline in their oral health. [ 1 – 3 ]. These alterations include oral mucositis that develops during and shortly after treatment, candida infections, difficulty speaking and eating, bleeding gums, and tissue fibrosis. [ 2 , 4 – 7 ]. Oral problems are distressing to patients, which may impact the patient’s physical, psychological, and social well-being and demonstrate a high degree of intensity [ 8 – 11 ]. Oral problems significantly affect global health status and health-related quality of life, especially those receiving head and neck radiation [ 12 – 14 ]. A multidisciplinary treatment team with experts from medicine, dentistry, nursing, nutrition, physical therapy, and counseling is crucial for promoting better oral care for patients receiving chemotherapy or hematopoietic stem-cell transplantation (HSCT) [ 15 ]. A panel of experts from the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology recommends (Level of Evidence III) the use of multiagent combination oral care procedures to avoid oral mucositis during chemotherapy, head and neck radiation therapy and hematopoietic stem cell transplantation [ 16 ]. Cancer management needs the assistance of a multidisciplinary team composed of medical oncologists, radiation oncologists, and dentists to conduct oral cavity examinations and identify warning signs and symptoms of oral alterations related to cancer treatment [ 17 ]. Compared with general oral care protocols, oral care protocols help decrease the severity of oral mucositis. In the global literature, the most often recommended strategy for handling oral complications in patients undergoing cancer treatment is good oral care, as nurses are considered to have adequate awareness and abilities to demonstrate the correct method of oral care [ 18 ]. It is an organizational requirement to follow a specific oral care protocol that will aid in treating oral symptoms. Using a safe and effective, systematic oral care protocol offers patients a proper way of performing oral care, such as cleaning, nourishing, guarding, and increasing salivation. Maintaining good oral hygiene can lessen the effects of oral problems [ 19 – 22 ]. According to many authors, applying a uniform oral care protocol for mucositis management reduces mucositis's occurrence, duration, and severity and decreases the worldwide negative impact of mucositis [ 21 , 23 – 25 ]. The literature supports the importance of oral care among cancer patients to reduce the adverse effects of cancer treatment. [ 1 , 7 , 26 ]. Despite the variability of oral care protocols, the overall results showed a significant reduction in oral complications when these protocols were adhered to properly. However, these reported studies did not investigate the clinical effectiveness of a simple oral care protocol for assessing oral complications among cancer patients. Hence, the present study aimed to assess the clinical effects of implementing an oral care protocol among cancer patients receiving chemotherapy and radiation therapy. Materials and methods The study was conducted between November 2015 and March 2020 in oncology-related wards of a tertiary care center Mangaluru, southern India. Patients, irrespective of the stage of cancer, who were undergoing chemoradiation, who were admitted to radiation oncology and special wards, who were scheduled for radiation therapy to the head and neck region, who were receiving only radiation therapy or postoperative radiation therapy, who were receiving at least 75% of both parotids in the radiation field, who received the radiation agent Linac (linear accelerator), who received an average radiation dose of 60–70 Gy and who were willing to participate in the study were included. Patients with cancers other than those affecting the oropharyngeal region were excluded. After obtaining the approval from the Institutional Review Committee, the ethical approval was obtained in accordance with the Declaration of Helsinki from the Institutional Ethics Committee Kasturba Medical College, Mangalore (IEC KMC MLR 03–18/65), and the study was registered at CTRI (CTRI/2015/04/005709). The sample size for the study was calculated for the primary outcome variable, oral health, using hypothesis testing of the two population means formula. [ 27 ]where Z1-α/2 = 1.96 (level of significance at 5%), Z1-β = 0.84 (power at 80%), \({\sigma }2\) = 15.4 (variance based on pilot study), and d2 = 10.6 (clinically significant difference in oral health status). Thirty-four participants were included in each group. Considering a 20% attrition rate, an additional six participants were included. Hence, the total sample size required for the intervention and control groups was 80. The intervention and control groups were selected from different wards to avoid sample contamination. Based on a random sampling number, an allocation sequence was generated. According to a computer-generated randomization list, participants were allocated to the intervention or control group (research randomizer available at www.randomizer.org ). Blocks were established to ensure equal numbers of subjects in each treatment group. Eighty head and neck cancer patients were recruited for the present study. Four blocks, with a fixed block size of 10, were set aside for each group to allocate a 1:1 ratio to maintain balance within the groups. Allocation concealment was achieved using sequentially numbered opaque sealed envelopes (SNOSE). Concealment was ensured by numbering the envelopes in advance, and during the intervention assignment, the envelopes were opened sequentially only after participant details were written on the appropriate envelope. With the help of random allocation software (RAS), a statistician performed sequence generation. A colleague, with the help of the randomization list, prepared SNOSE. The intervention group received an oral care protocol, an oral care kit, and patient education materials, which were prepacked in a ziplock sachet and numbered for each patient according to the randomization schedule. The subject expert enrolled the participants, and the nurse coordinator, who was not involved in the care of recruited patients, was assigned to open the envelopes and allocate the patients to interventions. The allocation sequence was concealed from the guide/subject experts. The subject expert in this study was responsible for diagnosing the oral complications, and this information was identified by the researcher from the records based on the treatment written in patient records for each complication. Patients were aware of their allocation to the study group. The researcher was responsible for providing oral care kits and education materials and explaining them to the patients, training staff nurses in the ward, implementing the oral care protocol, and documenting oral care. The researcher and trained staff nurses were aware of the allocation. The outcome assessor (subject expert) was blinded to the allocation and the assessment of outcomes. Hence, this was an outcome-blinded study. The study's progress in terms of enrollment, allocation, follow-up, and subsequent data analysis is summarized in the CONSORT flow diagram (Fig. 1 ). Tools The demographic data of the patients was collected during the patient's first visit after providing informed consent from both the intervention and control groups. Clinical Proforma was developed to measure the clinical details of the participants, which consisted of type/location of cancer, stage of cancer, type of treatment, chemotherapy drug, radiation dose, and body mass index (BMI), which were obtained from the records. The oral health and activity assessment tool assessed functional aspects and oral activities, including pain, taste, infection, saliva, lips, teeth, tongue, and mucous membrane. Self-oral care, speaking, chewing, and swallowing were among the activities. Every element was assigned a score according to its appearance. The final score was thirty. A score of 10 denoted good dental health, a score of 11–20 indicated moderate risk, and a score of 21–30 indicated high risk of oral problems. The patients were assessed daily after the oral care kit was introduced to them until their cancer treatment course was completed using a checklist. The expected duration for completing the treatment was 1½ months, which meant a minimum of 6 assessments during their stay. The reliability of the oral health assessment tool was established using an interrater reliability technique. The researcher and a nurse independently observed oral health among 20 patients, and the calculated reliability coefficient was (r = 0.87), which showed agreement between the raters. The WHO oral mucositis grading scale is commonly used in clinics to evaluate oral mucositis. [ 28 ]. It is graded from 0 to 4. This tool was classified as Grade 0 = no symptoms; Grade 1 = soreness and erythema; Grade 2 = erythema, ulcers, and patients can swallow a solid diet; Grade 3 = ulcers, extensive erythema, patients cannot swallow a solid diet; and Grade 4 = mucositis to the extent that alimentation is not possible. The reliability of the oral mucositis grading scale was established with an interrater reliability technique. The researcher and a nurse independently observed oral health among 15 patients, and the calculated reliability coefficient was (r = 0.94), which showed agreement between the raters. The oral complication incidence checklist consisted of 9 oral complications and their days of occurrence after the initiation of radiation therapy/chemoradiation. The complications assessed were oral mucositis, taste loss, swallowing difficulty, speaking difficulty, oral candida infection, xerostomia, bleeding gums, and nutritional imbalance. The treating physician recorded the treatment details on the care sheet when these complications were identified. Information was collected from the patient records where the treating oncologist had written the prescription. Intervention details Oral care intervention protocol (OCIP): Intervention group The intervention group received this study's oral care based on the oral care intervention protocol (OCIP). The researcher administered an oral care kit and education materials and trained the patients. The trained staff nurses in the ward helped implement oral care per the protocol and documented oral care. The oral care kit used in this study consisted of an ultrasoft bristle toothbrush, fluoridated toothpaste, oral rinses (salt, baking soda), chewy tubes, a mirror, a pen torch, a denture brush, a denture container, an ice cube box, a water bottle, and patient educational material (leaflet on oral care during treatment and after discharge, on oral complications, menu plan during the treatment). The patient education materials were validated by seven experts from oral medicine and radiology, radiation oncology, medical oncology, and medical-surgical nursing. Patient education material was translated into the local language, Kannada, and retranslated to the English version of the education leaflet and compared with the translated English version. This was done to check for any deviation from the original content due to translation errors by giving the data to a language expert for verification. Control group The control group received routine oral care per the hospital's Standard of Care (SOC). Both the intervention and control groups were given regular monitoring, treatment, and follow-up services delivered by physicians, nurses, and other healthcare team members. (Table 1 ) Table 1 Schematic representation of the research design Groups Pretest Intervention Posttest (6 weeks) Intervention R - X Oral care intervention protocol (OCIP) 0 1 Oral Health Oral complications Control R - Standard of care of oral care Keywords : R random assignment/randomization, O observation, 0 1 Posttest Data collection process An intervention was launched in two stages following creating a systematic oral hygiene strategy. Here, the patients received oral care through the research intervention, which included providing denture care, reading patient education materials, chewing the chewed tube before eating, brushing with an ultrasoft toothbrush and fluoridated toothpaste, and rinsing the mouth with soda bicarbonate. The patient underwent this oral care procedure four times a day. In addition to these interventions, the patient received a detailed meal plan that specified what foods one should eat and what she should avoid while undergoing therapy, as well as instructions on how much water one should drink each day, two to three liters, to improve the hydration status. This intervention phase included a one-year follow-up period for the patients once they completed their radiation therapy/chemoradiation by auditing the patient records. Informed consent was obtained from the participants, and Demographic Proforma was collected. The primary outcome measures in this study were the incidence of oral complications, oral mucositis, and oral health status. The occurrence of oral complications was collected from patient records and patients' verbalization of the oral problems. The WHO mucositis grading scale was used to assess oral mucositis. Oral health was assessed with a structured checklist. These tools were used once every week until the patient completed the prescribed dose of radiation therapy/chemoradiation. A documentation audit of patient records concerning the implementation of oral care and oral complications occurred during the study period. Results In the present study, most participants were included, i.e., 51.2% in the intervention group and 52.5% in the 56-year-old and older age group. Most patients were males, with 92.5% in the intervention group and 87.5% in the control group. Most patients, i.e., 40% in the intervention group and 37.5% in the control group, reported having a primary education. Seventeen (56.7%) patients in the intervention group and 13 (43.3%) in the control group had tongue cancer. (Table 2 ) Table 2 Sociodemographic characteristics of patients N = 80 Variables Intervention (n = 40) Control (n = 40) p-value f % f % Age in years 18–55 18 48.6 19 47.5 1.0 56 and > 22 51.2 21 52.5 Gender Male 37 92.5 35 87.5 .712 Female 3 7.5 5 12.5 Education Illiterate 15 37.5 13 32.5 Primary education 16 40 15 37.5 .706 Higher Secondary 7 17.5 11 27.5 Graduation 2 5 1 2.5 Type and location of the cancer Tongue 17 42.5 13 32.5 Buccal mucosa 3 7.5 7 17.5 Larynx 1 2.5 1 2.5 Supraglottis 3 7.5 4 10 Hypopharynx 6 15 5 12.5 .706 Oropharynx 7 17.5 6 15 Tonsil 1 2.5 0 0 Maxilla 0 0 1 2.5 Pyriform fossa 1 2.5 2 5 Glottis 1 2.5 0 0 Nasopharynx 0 0 1 2.5 BMI Malnourished 8 20 8 20 Underweight 10 25 15 37.5 .521 Normal 19 47.5 16 40 Overweight 3 7.5 1 2.5 P > .05 Overall, 23 (57.5%) head and neck cancer patients in the intervention group and 27 (57.4%) in the control group received chemoradiation therapy. Among patients who received chemoradiation therapy, most were treated with cytoplatin and kemocarb as chemotherapy agents. On average, most patients in the intervention (29 [72.5%]) and control (34 [85%]) groups received 70 Gy of radiation. Concerning the TNM classification, 20 (50%) and 15 (37.5%) of the head and neck cancer patients were in the T4 subgroup, 21 (52.5%) and 25 (62.5%) were in the N2 subgroup, and 34 (85%) and 32 (80%) were in the Mx subgroup in the intervention and control groups, respectively. Most of the patients, 19 (47.5%) in the intervention group and 17 (42.5%) in the control group, had stage IV cancer at diagnosis. (Table 3 ) Table 3 : Description of the treatment and staging details N = 80 Table 3 Description of the treatment and staging details N = 80 Variables Intervention (n = 40) Control (n = 40) p-value f % F % Type of treatment Radiation therapy 17 42.5 13 32.5 .173 Chemoradiation 23 57.5 27 67.5 Chemoradiation Agent Cytoplatin 9 39.13 10 25 Cisplatin 2 8.69 0 0 .290 Kemocarb 8 34.78 10 25 Gefitinib 1 4.34 3 7.5 Chemoplat 2 8.69 4 10 Unicarb 1 4.34 0 0 Radiation therapy Dose in Grays (Gy) 60 4 10 3 7.5 .343 66 7 17.5 3 7.5 70 29 72.5 34 85 TNM classification Tumor .148 T1 3 7.5 0 0 T2 7 17.5 9 22.5 T3 10 25 16 40 T4 20 50 15 37.5 Node .569 N0 12 30 12 30 N1 3 7.5 1 2.5 N2 21 52.5 25 62.5 N3 4 10 2 5 Metastasis .770 Mx 34 85 32 80 M0 6 15 8 20 Stage of cancer .687 I Early localized 1 2.5 1 2.5 II Early locally advanced 8 20 8 20 III Late locally advanced 12 30 14 35 IV Metastasized 19 47.5 17 42.5 P > .05 Effect of the Oral Care Intervention Protocol (OCIP) on Oral Health The results of the present study showed that compared to the control group, improvement in oral health was not statistically significant among patients in the intervention group [F = (.596), p = .442]. However, the interaction effect (time × group) was significant [F = (1.636), p = .175]. This result indicated that the group changed over time and differed across the groups. (Fig. 2 ) Repeated measures ANOVA revealed a significant effect of time (within the group) [F (401.982), p < .001]. This indicates a significant within-group effect and can be interpreted as patients in both groups improving their oral health over time. Compared to routine care, oral care intervention improved oral health among cancer patients receiving head and neck radiation therapy/chemoradiation. (Table 4 ) Table 4 Repeated measures ANOVA on the effectiveness of the oral care intervention protocol on oral health N = 80 Variable Groups F df P value ղ p 2 Intervention (n = 40) Time 401.982 5,390 .001 .837 Oral Health Control (n = 40) Group Time X Group .596 1.636 1,78 5,390 .442 .175 .008 .021 Note: Score range 10–30. Time refers to within-group effects, the group refers to between-group effects, and time X refers to interaction effects. SD – standard deviation = F ratio, df = degrees of freedom, p – level of significance (< .05), ղ p2 = partial eta squared (effect size). A lower score on the oral health assessment checklist indicated better health, and as the score increased, it indicated changes in the structural and functional aspects of the mouth. This profile plot also indicated better oral health in the intervention group than in the control group. More definite differences in the oral health scores were observed between 3 and 5 weeks, indicating that as the intervention progressed, improvements in oral health were observed in the intervention group compared to the control group. Compared to routine care, oral care intervention improved oral health among cancer patients receiving head and neck radiation therapy/chemoradiation. Effect of the oral care intervention protocol (OCIP) on oral structure and function. As treatment progressed, the severity of the structural changes and functional activities increased in both groups over the week's severity of the oral problems, and they also increased in both groups. Table 5 Comparison of mean days of incidence of oral complications N = 80 Oral complications group Mean (SD) F Mean difference CI (difference) Independent sample t-test (pdf) p-value Mucositis Intervention control 17.12 (7.58) 11.02 (4.22) 14.031 6.1 3.36–48.83 4.444 (78) < 0.001 * Chewing difficulty Intervention control 17.12 (7.26) 13.88 (6.00) 1.642 3.25 .28–6.21 2.181 (78) .032* Speaking difficulty Intervention control 17.55(7.00) 16.05(5.93) .500 1.5 -1.38-4.38 1.304(78) .482 Candida Infection Intervention control 19.68(9.51) 18.92(6.04) 1.841 1.8 -2.37-5.97 .858(78) .179 Xerostomia Intervention control 20.72(10.47) 17.58(8.14) .802 1.62 -2.34-5.59 .815(78) .417 Bleeding gums Intervention control 19.68(9.51) 18.92(6.04) 1.826 .75 -2.79-4.29 .421(78) .675 Nutritional imbalance Intervention control 20.05(6.33) 21.32(9.01) 1.312 1.27 -2.19-4.74 .732(78) .466 *P < .05 Table 5 shows that, on average, it took nearly 17 days to develop mucositis in the experimental group compared with the control group, where it occurred in 11 days. The mean difference of 6 days between the intervention and control groups concerning mucositis incidence was statistically significant (p < 0.001). On average, it took nearly 17 days to develop chewing difficulty in the experimental group compared with the control group, which occurred in 14 days. The mean difference of 3 days between the intervention and control groups concerning the incidence of chewing difficulty was statistically significant (p = .032). This indicates that the treatment effectively delays the incidence of mucositis and chewing difficulty in the intervention group. However, complications such as speaking difficulty occurred on an average of 18 days in the intervention group compared with those in the control group at 16 days (p = .482); on average, it took nearly 20 days to develop oral candida infection in the intervention group compared with that in the control group at 19 days (p = .179); on average, it took nearly 21 days to develop xerostomia in the intervention group compared with that in the control group at 18 days (p = .417); on average, it took nearly 20 days to develop bleeding gums in the intervention group compared with that in the control group at 19 days (p = .675). On average, it took nearly 20 days to develop a nutritional imbalance in the intervention group compared to the control group at 21 days (p = .466). These complications were not statistically significant, indicating that the intervention was effective for these oral complications. Table 6 Comparison of the median days of incidence of oral complications Mann‒Whitney U test N = 80 Oral complications Group Median Mean(SD) (Q1, Q3) Mann‒Whitney ‘U’ P value Taste loss Intervention 12.5 12.62(6.96) (8,16) 492 .828 Control 10.5 12.38(6.26) (9,16.25) Swallowing difficulty Intervention 12 12.72(6.52) (9,16) 527 . 009* Control 16 16.95(7.48) (11,21) *P < .05 The median number of days to swallowing difficulty was four days greater in the intervention group than in the control group, indicating that the intervention effectively reduced swallowing difficulty (p = .009). Compared with those in the control group, complications such as taste loss were not significantly different (p = .828), indicating that the intervention was ineffective in reducing the severity of taste loss in the intervention group. (Table 6 ) Discussion The present study used an oral care kit, including all evidence-based interventions for patients receiving head and neck radiation/chemoradiation. In the literature, various studies have used different procedures and components to deliver oral care. An expert committee reported using empirically tested best clinical practices as standards for practitioners' routine oral care of cancer patients. [ 21 ]. An oral care module to address oral care in cancer care included critical facets of oral care, assessment, and treatment in London, UK. This module included various strategies for oral care at hospitals, hospices, and home locations. [ 29 ]. An oral care protocol was developed by Sieracki et al. in Pittsburgh, USA. It was founded on a patient-centered approach guided by a nurse who reviewed cancer treatment options and how they affected the oral cavity. This new regimen called for flossing, rinsing the mouth with regular saline, and examination of the oral cavity. [ 30 ] Oral hygiene procedures and routine use of a mouth rinse solution were reported as the basis of a suitable oral care protocol. This further promoted strict adherence to the oral care protocol, which can help prevent oral complications [ 31 ]. An ongoing education update for oral care for head and neck cancer symptom management in Iowa City, USA, suggested using an oral kit, which included an ultrasoft toothbrush, dental floss, salt, baking soda packets for oral rinsing, Biotene-based toothpaste, a denture cup and other small cups for mixing. The study reported a decrease in the effects of oral mucositis during and after radiation treatment [ 32 ]. Similar findings were reported in a study that showed the effectiveness of consistent professional oral health care in lowering the risk of oral mucositis in patients receiving chemotherapy for breast cancer in Japan. The intervention group received weekly expert oral care, which included dental cleaning, scaling, brushing directions, and lifestyle guidance [ 32 ]. The present study reported that the mean difference observed over several days between the intervention and control groups indicated that the intervention was effective in delaying the incidence of mucositis (p ≤ 0.001) and chewing difficulty (p ≤ 0.032), which was statistically significant. The median number of days to swallowing difficulty was more significant in the intervention group than in the control group, indicating that the intervention effectively reduced swallowing difficulty (p = .009). A total of 63 (72%) patients had xerostomia, 55 (63%) had taste changes, 50 (57%) had weight loss, 50 (40%) had dysphagia, and 35 (40%) had self-reported oral dysfunction related to oral mucositis and received chemotherapy and head and neck radiation therapy. [ 11 ]. More patients developed mucositis in the self-care group than in the professional oral-care intervention group in a study where an oral-care protocol was introduced. [ 33 ]. In one study, the standard care alone group experienced mucositis symptoms more frequently than the standard care plus plain ice and standard care plus flavored ice groups. [ 34 ]. An oral care protocol was introduced in Michigan, USA, to promote early detection and management of stomatitis. An increased number of cases were reported after implementation, i.e., 11 compared to the retrospective records of 5 patients. Nurses perceived a benefit for their patients and reported good nursing practices after the intervention. [ 35 ]. A rigorous oral care regimen alone cannot reduce the incidence of severe oral mucositis in patients with HNC receiving chemoradiotherapy. Regular dental care programs may indirectly help enhance treatment compliance by lowering the risk of infection. [ 36 ]. According to our findings, a specific oral hygiene regimen reduced the development of mucositis and was negatively correlated with opportunistic infections. [ 37 ]. The progress of existing knowledge toward the common goal of improved patient outcomes shared by healthcare professionals is facilitated by the use of many types of evidence in developing an organized plan of care for oral mucositis among patients with cancer. [ 38 ]. Applying best practices in four hematology–oncology contexts is feasible for improving oral mucositis prevention and therapy for cancer patients. [ 3 ]. However, there are limitations inherent to the present study. The sample was representative of cancer patients who met the inclusion criteria mentioned in the study. The researchers could not observe the practice of the oral care intervention, as it was difficult for the researcher to be present throughout the intervention. Only verbal reports of the continuity of oral care by the patients and their relatives were collected during each visit concerning adherence to the protocol. In addition, the researchers and participants were not blinded to the intervention. Conclusion Oral complications are the most common post-radiation therapy/chemotherapy-associated complications and may cause significant morbidity and mortality. A combined effort by multiple professionals, such as medical oncologists, radiation oncologists, oral medicine specialists, and oncology nurses, can result in the development of simple yet effective patient care interventions, including specific oral care protocols and oral care kit interventions for oral care of cancer patients receiving head and neck radiation/chemoradiation. An oral care intervention protocol effectively delays the incidence of oral complications such as oral mucositis, chewing difficulty, and swallowing difficulty but does not prevent these complications. However, the incidence of complications such as oral candida infection, speaking difficulty, bleeding gums, xerostomia, taste loss, and nutritional imbalance did not significantly differ, indicating that treatment was ineffective for these oral complications. Significant mean and median differences in the incidence of oral complications were detected between the intervention and control groups. These data suggest that the oral care intervention protocol is clinically valuable for maintaining overall oral health among cancer patients receiving head and neck radiation/chemoradiation. The findings of this study can also contribute to justifying the use of an oral care kit, including all evidence-based interventions for patients receiving head and neck radiation/chemoradiation, which is potentially useful for future comparisons. 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Archives of Medical Science. 2014;10(6):1153–9. Elad S, Raber-Durlacher JE, Brennan MT, Saunders DP, Mank AP, Zadik Y, et al. Basic oral care for hematology–oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT). Supportive Care in Cancer. 2015;23(1):223–36. Hong CHL, Gueiros LA, Fulton JS, Cheng KKF, Kandwal A, Galiti D, et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guidelines. Supportive Care in Cancer. 2019;27(10):3949–67. Pai RR, Ongole R. Nurses’ knowledge and education about oral care of cancer patients undergoing chemotherapy and radiation therapy. Indian journal of palliative care. 2015;21(2):225. Cooper D, Kim J, Duderstadt K, Stewart R, Lin B, Alkon A. Interprofessional oral health education improves knowledge, confidence, and practice for pediatric healthcare providers. Frontiers in Public health. 2017;5:209. Cohen EE, LaMonte SJ, Erb NL, Beckman KL, Sadeghi N, Hutcheson KA, et al. American Cancer Society head and neck cancer survivorship care guideline. CA: a cancer journal for clinicians. 2016;66(3):203–39. Quinn BG, Campbell F, Fulman L, Harding J, Dargan S, Mathlin J, et al. Oral care of patients in the cancer setting. Cancer Nursing Practice. 2023;22(6). Rubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy–induced oral and gastrointestinal mucositis. Cancer: Interdisciplinary International Journal of the American Cancer Society. 2004;100(S9):2026–46. Epstein JB, Barasch A. Oral and dental health in head and neck cancer patients. Multidisciplinary Care of the Head and Neck Cancer Patient. 2018:43–57. Lalla RV, Saunders DP, Peterson DE. Chemotherapy or radiation-induced oral mucositis. Dental clinics. 2014;58(2):341–9. Moslemi D, Nokhandani AM, Otaghsaraei MT, Moghadamnia Y, Kazemi S, Moghadamnia AA. Management of chemo/radiation-induced oral mucositis in patients with head and neck cancer: A review of the current literature. Radiotherapy and Oncology. 2016;120(1):13–20. Naidu MUR, Ramana GV, Rani PU, Suman A, Roy P. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia. 2004;6(5):423–31. Rankin KV, Jones DL, Redding S. Oral health in cancer therapy. Tex Dent J. 2009;126(5):389–97. Kadam P, Bhalerao S. Sample size calculation. International journal of Ayurveda research. 2010;1(1):55. World Health O. WHO handbook for reporting results of cancer treatment. Geneva: World Health Organization; 1979. Quinn B. Addressing mouth care in cancer careecc_1164 526. European Journal of Cancer Care. 2009;18:526. Sieracki RL, Voelz LM, Johannik TM, Kopaczewski DM, Kelly Hubert R. Development and implementation of an oral care protocol for patients with cancer. Clinical journal of oncology nursing. 2009;13(6):718. Broadfield L. Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy: Quick Reference Version: Cancer Care Nova Scotia; 2006. Cullen L, Baumler S, Farrington M, Dawson C, Folkmann P, Brenner L. CE: Oral Care for Head and Neck Cancer Symptom Management. AJN The American Journal of Nursing. 2018;118(1):24–34. Saito H, Watanabe Y, Sato K, Ikawa H, Yoshida Y, Katakura A, et al. Effects of professional oral health care on reducing the risk of chemotherapy-induced oral mucositis. Supportive Care in Cancer. 2014;22(11):2935–40. Nikoletti S, Hyde S, Shaw T, Myers H, Kristjanson LJ. Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of clinical nursing. 2005;14(6):750–3. Caplinger JRNMSAOCN, Royse MRNMSNC, Martens JRNBSNOCN. Implementation of an Oral Care Protocol to Promote Early Detection and Management of Stomatitis. Clinical Journal of Oncology Nursing. 2010;14(6):799–802. Yokota T, Tachibana H, Konishi T, Yurikusa T, Hamauchi S, Sakai K, et al. Multicenter phase II study of an oral care program for patients with head and neck cancer receiving chemoradiotherapy. Supportive Care in Cancer. 2016;24(7):3029–36. Yoneda S, Imai S, Hanada N, Yamazaki T, Senpuku H, Ota Y, et al. Effects of oral care on development of oral mucositis and microorganisms in patients with esophageal cancer. Japanese journal of infectious diseases. 2007;60(1):23. Eilers J, Million R. Clinical Update: Prevention and Management of Oral Mucositis in Patients with Cancer. Seminars in Oncology Nursing. 2011;27(4):e1-e16. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4534806","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317247945,"identity":"d73a91c2-d1c2-4210-8ba8-f1921db95ef3","order_by":0,"name":"Radhika R Pai","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Radhika","middleName":"R","lastName":"Pai","suffix":""},{"id":317247946,"identity":"e9ee0b60-3667-4324-bbc3-98a6a3d41438","order_by":1,"name":"Sourjya Banerjee","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Sourjya","middleName":"","lastName":"Banerjee","suffix":""},{"id":317247947,"identity":"b3349e21-28a1-4732-b1ef-ae258af910bd","order_by":2,"name":"Linu Sara George","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Linu","middleName":"Sara","lastName":"George","suffix":""},{"id":317247948,"identity":"1e786121-6c0f-4aaf-8474-7169a495a66b","order_by":3,"name":"Anice George","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Anice","middleName":"","lastName":"George","suffix":""},{"id":317247949,"identity":"7cf8c9fa-f791-497b-8101-2ae46d92fb6e","order_by":4,"name":"Ravikiran ongole","email":"data:image/png;base64,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","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":true,"prefix":"","firstName":"Ravikiran","middleName":"","lastName":"ongole","suffix":""}],"badges":[],"createdAt":"2024-06-05 14:29:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4534806/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4534806/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60601086,"identity":"77e38339-b587-434a-9c7d-079ca9e42b5a","added_by":"auto","created_at":"2024-07-18 16:04:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2338097,"visible":true,"origin":"","legend":"\u003cp\u003eConsolidated Standards of Reporting Trials (CONSORT) flow chart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4534806/v1/0b78e206c0cc3c1ad252f38e.png"},{"id":60601090,"identity":"6c0a2847-ce36-46ce-b664-ce903003da5d","added_by":"auto","created_at":"2024-07-18 16:04:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52476,"visible":true,"origin":"","legend":"\u003cp\u003eProfile plot showing changes in oral health across six weeks\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4534806/v1/7299676e229d0fa108f80e60.png"},{"id":61449871,"identity":"42155659-c7da-44dc-b940-45c0e572935c","added_by":"auto","created_at":"2024-07-31 01:26:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3738164,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4534806/v1/da168847-cbd4-4754-bb83-d6b93a6f312b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of the Oral Care Intervention Protocol (OCIP) on the Oral Health Scores of Head and Neck Cancer Patients Receiving Radiation/Chemoradiation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCancer patients receiving chemotherapy and head and neck radiation therapy may experience a notable sudden decline in their oral health. [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These alterations include oral mucositis that develops during and shortly after treatment, candida infections, difficulty speaking and eating, bleeding gums, and tissue fibrosis. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOral problems are distressing to patients, which may impact the patient\u0026rsquo;s physical, psychological, and social well-being and demonstrate a high degree of intensity [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Oral problems significantly affect global health status and health-related quality of life, especially those receiving head and neck radiation [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA multidisciplinary treatment team with experts from medicine, dentistry, nursing, nutrition, physical therapy, and counseling is crucial for promoting better oral care for patients receiving chemotherapy or hematopoietic stem-cell transplantation (HSCT) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A panel of experts from the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology recommends (Level of Evidence III) the use of multiagent combination oral care procedures to avoid oral mucositis during chemotherapy, head and neck radiation therapy and hematopoietic stem cell transplantation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Cancer management needs the assistance of a multidisciplinary team composed of medical oncologists, radiation oncologists, and dentists to conduct oral cavity examinations and identify warning signs and symptoms of oral alterations related to cancer treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Compared with general oral care protocols, oral care protocols help decrease the severity of oral mucositis. In the global literature, the most often recommended strategy for handling oral complications in patients undergoing cancer treatment is good oral care, as nurses are considered to have adequate awareness and abilities to demonstrate the correct method of oral care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It is an organizational requirement to follow a specific oral care protocol that will aid in treating oral symptoms. Using a safe and effective, systematic oral care protocol offers patients a proper way of performing oral care, such as cleaning, nourishing, guarding, and increasing salivation. Maintaining good oral hygiene can lessen the effects of oral problems [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. According to many authors, applying a uniform oral care protocol for mucositis management reduces mucositis's occurrence, duration, and severity and decreases the worldwide negative impact of mucositis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature supports the importance of oral care among cancer patients to reduce the adverse effects of cancer treatment. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Despite the variability of oral care protocols, the overall results showed a significant reduction in oral complications when these protocols were adhered to properly. However, these reported studies did not investigate the clinical effectiveness of a simple oral care protocol for assessing oral complications among cancer patients. Hence, the present study aimed to assess the clinical effects of implementing an oral care protocol among cancer patients receiving chemotherapy and radiation therapy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe study was conducted between November 2015 and March 2020 in oncology-related wards of a tertiary care center Mangaluru, southern India. Patients, irrespective of the stage of cancer, who were undergoing chemoradiation, who were admitted to radiation oncology and special wards, who were scheduled for radiation therapy to the head and neck region, who were receiving only radiation therapy or postoperative radiation therapy, who were receiving at least 75% of both parotids in the radiation field, who received the radiation agent Linac (linear accelerator), who received an average radiation dose of 60\u0026ndash;70 Gy and who were willing to participate in the study were included. Patients with cancers other than those affecting the oropharyngeal region were excluded. After obtaining the approval from the Institutional Review Committee, the ethical approval was obtained in accordance with the Declaration of Helsinki from the Institutional Ethics Committee Kasturba Medical College, Mangalore (IEC KMC MLR 03\u0026ndash;18/65), and the study was registered at CTRI (CTRI/2015/04/005709).\u003c/p\u003e \u003cp\u003eThe sample size for the study was calculated for the primary outcome variable, oral health, using hypothesis testing of the two population means formula. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]where Z1-α/2\u0026thinsp;=\u0026thinsp;1.96 (level of significance at 5%), Z1-β\u0026thinsp;=\u0026thinsp;0.84 (power at 80%), \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\sigma }2\\)\u003c/span\u003e\u003c/span\u003e= 15.4 (variance based on pilot study), and d2\u0026thinsp;=\u0026thinsp;10.6 (clinically significant difference in oral health status). Thirty-four participants were included in each group. Considering a 20% attrition rate, an additional six participants were included. Hence, the total sample size required for the intervention and control groups was 80.\u003c/p\u003e \u003cp\u003eThe intervention and control groups were selected from different wards to avoid sample contamination. Based on a random sampling number, an allocation sequence was generated. According to a computer-generated randomization list, participants were allocated to the intervention or control group (research randomizer available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.randomizer.org\" target=\"_blank\"\u003ewww.randomizer.org\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.randomizer.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Blocks were established to ensure equal numbers of subjects in each treatment group. Eighty head and neck cancer patients were recruited for the present study. Four blocks, with a fixed block size of 10, were set aside for each group to allocate a 1:1 ratio to maintain balance within the groups. Allocation concealment was achieved using sequentially numbered opaque sealed envelopes (SNOSE). Concealment was ensured by numbering the envelopes in advance, and during the intervention assignment, the envelopes were opened sequentially only after participant details were written on the appropriate envelope.\u003c/p\u003e \u003cp\u003eWith the help of random allocation software (RAS), a statistician performed sequence generation. A colleague, with the help of the randomization list, prepared SNOSE. The intervention group received an oral care protocol, an oral care kit, and patient education materials, which were prepacked in a ziplock sachet and numbered for each patient according to the randomization schedule. The subject expert enrolled the participants, and the nurse coordinator, who was not involved in the care of recruited patients, was assigned to open the envelopes and allocate the patients to interventions. The allocation sequence was concealed from the guide/subject experts. The subject expert in this study was responsible for diagnosing the oral complications, and this information was identified by the researcher from the records based on the treatment written in patient records for each complication.\u003c/p\u003e \u003cp\u003ePatients were aware of their allocation to the study group. The researcher was responsible for providing oral care kits and education materials and explaining them to the patients, training staff nurses in the ward, implementing the oral care protocol, and documenting oral care. The researcher and trained staff nurses were aware of the allocation. The outcome assessor (subject expert) was blinded to the allocation and the assessment of outcomes. Hence, this was an outcome-blinded study.\u003c/p\u003e \u003cp\u003eThe study's progress in terms of enrollment, allocation, follow-up, and subsequent data analysis is summarized in the CONSORT flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTools\u003c/h2\u003e \u003cp\u003eThe demographic data of the patients was collected during the patient's first visit after providing informed consent from both the intervention and control groups. Clinical Proforma was developed to measure the clinical details of the participants, which consisted of type/location of cancer, stage of cancer, type of treatment, chemotherapy drug, radiation dose, and body mass index (BMI), which were obtained from the records.\u003c/p\u003e \u003cp\u003e The oral health and activity assessment tool assessed functional aspects and oral activities, including pain, taste, infection, saliva, lips, teeth, tongue, and mucous membrane. Self-oral care, speaking, chewing, and swallowing were among the activities. Every element was assigned a score according to its appearance. The final score was thirty. A score of 10 denoted good dental health, a score of 11\u0026ndash;20 indicated moderate risk, and a score of 21\u0026ndash;30 indicated high risk of oral problems. The patients were assessed daily after the oral care kit was introduced to them until their cancer treatment course was completed using a checklist. The expected duration for completing the treatment was 1\u0026frac12; months, which meant a minimum of 6 assessments during their stay. The reliability of the oral health assessment tool was established using an interrater reliability technique. The researcher and a nurse independently observed oral health among 20 patients, and the calculated reliability coefficient was (r\u0026thinsp;=\u0026thinsp;0.87), which showed agreement between the raters.\u003c/p\u003e \u003cp\u003e The WHO oral mucositis grading scale is commonly used in clinics to evaluate oral mucositis. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It is graded from 0 to 4. This tool was classified as Grade 0\u0026thinsp;=\u0026thinsp;no symptoms; Grade 1\u0026thinsp;=\u0026thinsp;soreness and erythema; Grade 2\u0026thinsp;=\u0026thinsp;erythema, ulcers, and patients can swallow a solid diet; Grade 3\u0026thinsp;=\u0026thinsp;ulcers, extensive erythema, patients cannot swallow a solid diet; and Grade 4\u0026thinsp;=\u0026thinsp;mucositis to the extent that alimentation is not possible. The reliability of the oral mucositis grading scale was established with an interrater reliability technique. The researcher and a nurse independently observed oral health among 15 patients, and the calculated reliability coefficient was (r\u0026thinsp;=\u0026thinsp;0.94), which showed agreement between the raters.\u003c/p\u003e \u003cp\u003eThe oral complication incidence checklist consisted of 9 oral complications and their days of occurrence after the initiation of radiation therapy/chemoradiation. The complications assessed were oral mucositis, taste loss, swallowing difficulty, speaking difficulty, oral candida infection, xerostomia, bleeding gums, and nutritional imbalance. The treating physician recorded the treatment details on the care sheet when these complications were identified. Information was collected from the patient records where the treating oncologist had written the prescription.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIntervention details\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eOral care intervention protocol (OCIP): Intervention group\u003c/h2\u003e \u003cp\u003eThe intervention group received this study's oral care based on the oral care intervention protocol (OCIP). The researcher administered an oral care kit and education materials and trained the patients. The trained staff nurses in the ward helped implement oral care per the protocol and documented oral care.\u003c/p\u003e \u003cp\u003e The oral care kit used in this study consisted of an ultrasoft bristle toothbrush, fluoridated toothpaste, oral rinses (salt, baking soda), chewy tubes, a mirror, a pen torch, a denture brush, a denture container, an ice cube box, a water bottle, and patient educational material (leaflet on oral care during treatment and after discharge, on oral complications, menu plan during the treatment).\u003c/p\u003e \u003cp\u003eThe patient education materials were validated by seven experts from oral medicine and radiology, radiation oncology, medical oncology, and medical-surgical nursing. Patient education material was translated into the local language, Kannada, and retranslated to the English version of the education leaflet and compared with the translated English version. This was done to check for any deviation from the original content due to translation errors by giving the data to a language expert for verification.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eControl group\u003c/h2\u003e \u003cp\u003eThe control group received routine oral care per the hospital's Standard of Care (SOC). Both the intervention and control groups were given regular monitoring, treatment, and follow-up services delivered by physicians, nurses, and other healthcare team members. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSchematic representation of the research design\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePretest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosttest (6 weeks)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eR\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eX\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOral care intervention protocol (OCIP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0\u003csub\u003e1\u003c/sub\u003e\u003c/p\u003e \u003cp\u003eOral Health\u003c/p\u003e \u003cp\u003eOral complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003eR\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStandard of care of oral care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eKeywords\u003c/b\u003e: R random assignment/randomization, O observation, 0\u003csub\u003e1\u003c/sub\u003e Posttest\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection process\u003c/h2\u003e \u003cp\u003e An intervention was launched in two stages following creating a systematic oral hygiene strategy. Here, the patients received oral care through the research intervention, which included providing denture care, reading patient education materials, chewing the chewed tube before eating, brushing with an ultrasoft toothbrush and fluoridated toothpaste, and rinsing the mouth with soda bicarbonate. The patient underwent this oral care procedure four times a day. In addition to these interventions, the patient received a detailed meal plan that specified what foods one should eat and what she should avoid while undergoing therapy, as well as instructions on how much water one should drink each day, two to three liters, to improve the hydration status. This intervention phase included a one-year follow-up period for the patients once they completed their radiation therapy/chemoradiation by auditing the patient records.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from the participants, and Demographic Proforma was collected. The primary outcome measures in this study were the incidence of oral complications, oral mucositis, and oral health status. The occurrence of oral complications was collected from patient records and patients' verbalization of the oral problems. The WHO mucositis grading scale was used to assess oral mucositis. Oral health was assessed with a structured checklist. These tools were used once every week until the patient completed the prescribed dose of radiation therapy/chemoradiation. A documentation audit of patient records concerning the implementation of oral care and oral complications occurred during the study period.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the present study, most participants were included, i.e., 51.2% in the intervention group and 52.5% in the 56-year-old and older age group. Most patients were males, with 92.5% in the intervention group and 87.5% in the control group. Most patients, i.e., 40% in the intervention group and 37.5% in the control group, reported having a primary education. Seventeen (56.7%) patients in the intervention group and 13 (43.3%) in the control group had tongue cancer. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of patients N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ef\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ef\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56 and \u0026gt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.712\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType and location of the cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTongue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuccal mucosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupraglottis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypopharynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOropharynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTonsil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxilla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyriform fossa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlottis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNasopharynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalnourished\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;.05\u003c/h2\u003e \u003cp\u003eOverall, 23 (57.5%) head and neck cancer patients in the intervention group and 27 (57.4%) in the control group received chemoradiation therapy. Among patients who received chemoradiation therapy, most were treated with cytoplatin and kemocarb as chemotherapy agents. On average, most patients in the intervention (29 [72.5%]) and control (34 [85%]) groups received 70 Gy of radiation. Concerning the TNM classification, 20 (50%) and 15 (37.5%) of the head and neck cancer patients were in the T4 subgroup, 21 (52.5%) and 25 (62.5%) were in the N2 subgroup, and 34 (85%) and 32 (80%) were in the Mx subgroup in the intervention and control groups, respectively. Most of the patients, 19 (47.5%) in the intervention group and 17 (42.5%) in the control group, had stage IV cancer at diagnosis. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cem\u003eDescription of the treatment and staging details\u003c/em\u003e N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescription of the treatment and staging details\u003c/em\u003e N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c12\" namest=\"c11\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003ef\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRadiation therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChemoradiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e67.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChemoradiation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAgent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCytoplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c12\" namest=\"c11\" rowspan=\"2\"\u003e \u003cp\u003e.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eKemocarb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGefitinib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChemoplat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUnicarb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiation therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDose in Grays (Gy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"12\" nameend=\"c12\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTNM classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"4\" nameend=\"c12\" namest=\"c11\" rowspan=\"5\"\u003e \u003cp\u003e.148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNode\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"4\" nameend=\"c12\" namest=\"c11\" rowspan=\"5\"\u003e \u003cp\u003e.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMetastasis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c12\" namest=\"c11\" rowspan=\"3\"\u003e \u003cp\u003e.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eM0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage of cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"4\" nameend=\"c12\" namest=\"c11\" rowspan=\"5\"\u003e \u003cp\u003e.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eI Early localized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eII Early locally advanced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIII Late locally advanced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIV Metastasized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c13\" namest=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;.05\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eEffect of the Oral Care Intervention Protocol (OCIP) on Oral Health\u003c/h2\u003e \u003cp\u003eThe results of the present study showed that compared to the control group, improvement in oral health was not statistically significant among patients in the intervention group [F = (.596), p\u0026thinsp;=\u0026thinsp;.442]. However, the interaction effect (time \u0026times; group) was significant [F = (1.636), p\u0026thinsp;=\u0026thinsp;.175]. This result indicated that the group changed over time and differed across the groups. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRepeated measures ANOVA revealed a significant effect of time (within the group) [F (401.982), p\u0026thinsp;\u0026lt;\u0026thinsp;.001]. This indicates a significant within-group effect and can be interpreted as patients in both groups improving their oral health over time. Compared to routine care, oral care intervention improved oral health among cancer patients receiving head and neck radiation therapy/chemoradiation. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRepeated measures ANOVA on the effectiveness of the oral care intervention protocol on oral health N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eղ p\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e401.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5,390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.837\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOral Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup Time X Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.596\u003c/p\u003e \u003cp\u003e1.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,78\u003c/p\u003e \u003cp\u003e5,390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.442\u003c/p\u003e \u003cp\u003e.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003cp\u003e.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: Score range 10\u0026ndash;30. Time refers to within-group effects, the group refers to between-group effects, and time X refers to interaction effects. SD \u0026ndash; standard deviation\u0026thinsp;=\u0026thinsp;F ratio, df\u0026thinsp;=\u0026thinsp;degrees of freedom, p \u0026ndash; level of significance (\u0026lt;\u0026thinsp;.05), ղ p2\u0026thinsp;=\u0026thinsp;partial eta squared (effect size).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e A lower score on the oral health assessment checklist indicated better health, and as the score increased, it indicated changes in the structural and functional aspects of the mouth. This profile plot also indicated better oral health in the intervention group than in the control group. More definite differences in the oral health scores were observed between 3 and 5 weeks, indicating that as the intervention progressed, improvements in oral health were observed in the intervention group compared to the control group. Compared to routine care, oral care intervention improved oral health among cancer patients receiving head and neck radiation therapy/chemoradiation.\u003c/p\u003e \u003cp\u003e\u003cb\u003e Effect of the oral care intervention protocol (OCIP) on oral structure and function.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e As treatment progressed, the severity of the structural changes and functional activities increased in both groups over the week's severity of the oral problems, and they also increased in both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean days of incidence of oral complications N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCI (difference)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndependent sample t-test (pdf)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucositis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.12 (7.58)\u003c/p\u003e \u003cp\u003e11.02 (4.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.36\u0026ndash;48.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.444 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChewing difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.12 (7.26)\u003c/p\u003e \u003cp\u003e13.88 (6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.28\u0026ndash;6.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.181 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.032*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpeaking difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.55(7.00)\u003c/p\u003e \u003cp\u003e16.05(5.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.38-4.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.304(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCandida Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.68(9.51)\u003c/p\u003e \u003cp\u003e18.92(6.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.37-5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.858(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eXerostomia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.72(10.47)\u003c/p\u003e \u003cp\u003e17.58(8.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.34-5.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.815(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.417\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding gums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.68(9.51)\u003c/p\u003e \u003cp\u003e18.92(6.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.79-4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.421(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNutritional imbalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003econtrol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.05(6.33)\u003c/p\u003e \u003cp\u003e21.32(9.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.19-4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.732(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows that, on average, it took nearly 17 days to develop mucositis in the experimental group compared with the control group, where it occurred in 11 days. The mean difference of 6 days between the intervention and control groups concerning mucositis incidence was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). On average, it took nearly 17 days to develop chewing difficulty in the experimental group compared with the control group, which occurred in 14 days. The mean difference of 3 days between the intervention and control groups concerning the incidence of chewing difficulty was statistically significant (p\u0026thinsp;=\u0026thinsp;.032). This indicates that the treatment effectively delays the incidence of mucositis and chewing difficulty in the intervention group.\u003c/p\u003e \u003cp\u003e However, complications such as speaking difficulty occurred on an average of 18 days in the intervention group compared with those in the control group at 16 days (p\u0026thinsp;=\u0026thinsp;.482); on average, it took nearly 20 days to develop oral candida infection in the intervention group compared with that in the control group at 19 days (p\u0026thinsp;=\u0026thinsp;.179); on average, it took nearly 21 days to develop xerostomia in the intervention group compared with that in the control group at 18 days (p\u0026thinsp;=\u0026thinsp;.417); on average, it took nearly 20 days to develop bleeding gums in the intervention group compared with that in the control group at 19 days (p\u0026thinsp;=\u0026thinsp;.675). On average, it took nearly 20 days to develop a nutritional imbalance in the intervention group compared to the control group at 21 days (p\u0026thinsp;=\u0026thinsp;.466). These complications were not statistically significant, indicating that the intervention was effective for these oral complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eComparison of the median days of incidence of oral complications\u003c/em\u003e Mann‒Whitney U test N\u0026thinsp;=\u0026thinsp;80\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMann‒Whitney \u0026lsquo;U\u0026rsquo;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTaste loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.62(6.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(8,16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.828\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.38(6.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9,16.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSwallowing difficulty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.72(6.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(9,16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.\u003cb\u003e009*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.95(7.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(11,21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/h2\u003e \u003cp\u003eThe median number of days to swallowing difficulty was four days greater in the intervention group than in the control group, indicating that the intervention effectively reduced swallowing difficulty (p\u0026thinsp;=\u0026thinsp;.009). Compared with those in the control group, complications such as taste loss were not significantly different (p\u0026thinsp;=\u0026thinsp;.828), indicating that the intervention was ineffective in reducing the severity of taste loss in the intervention group. (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study used an oral care kit, including all evidence-based interventions for patients receiving head and neck radiation/chemoradiation. In the literature, various studies have used different procedures and components to deliver oral care. An expert committee reported using empirically tested best clinical practices as standards for practitioners' routine oral care of cancer patients. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. An oral care module to address oral care in cancer care included critical facets of oral care, assessment, and treatment in London, UK. This module included various strategies for oral care at hospitals, hospices, and home locations. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn oral care protocol was developed by Sieracki et al. in Pittsburgh, USA. It was founded on a patient-centered approach guided by a nurse who reviewed cancer treatment options and how they affected the oral cavity. This new regimen called for flossing, rinsing the mouth with regular saline, and examination of the oral cavity. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Oral hygiene procedures and routine use of a mouth rinse solution were reported as the basis of a suitable oral care protocol. This further promoted strict adherence to the oral care protocol, which can help prevent oral complications [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. An ongoing education update for oral care for head and neck cancer symptom management in Iowa City, USA, suggested using an oral kit, which included an ultrasoft toothbrush, dental floss, salt, baking soda packets for oral rinsing, Biotene-based toothpaste, a denture cup and other small cups for mixing. The study reported a decrease in the effects of oral mucositis during and after radiation treatment [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similar findings were reported in a study that showed the effectiveness of consistent professional oral health care in lowering the risk of oral mucositis in patients receiving chemotherapy for breast cancer in Japan. The intervention group received weekly expert oral care, which included dental cleaning, scaling, brushing directions, and lifestyle guidance [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study reported that the mean difference observed over several days between the intervention and control groups indicated that the intervention was effective in delaying the incidence of mucositis (p\u0026thinsp;\u0026le;\u0026thinsp;0.001) and chewing difficulty (p\u0026thinsp;\u0026le;\u0026thinsp;0.032), which was statistically significant. The median number of days to swallowing difficulty was more significant in the intervention group than in the control group, indicating that the intervention effectively reduced swallowing difficulty (p\u0026thinsp;=\u0026thinsp;.009).\u003c/p\u003e \u003cp\u003eA total of 63 (72%) patients had xerostomia, 55 (63%) had taste changes, 50 (57%) had weight loss, 50 (40%) had dysphagia, and 35 (40%) had self-reported oral dysfunction related to oral mucositis and received chemotherapy and head and neck radiation therapy. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. More patients developed mucositis in the self-care group than in the professional oral-care intervention group in a study where an oral-care protocol was introduced. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In one study, the standard care alone group experienced mucositis symptoms more frequently than the standard care plus plain ice and standard care plus flavored ice groups. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. An oral care protocol was introduced in Michigan, USA, to promote early detection and management of stomatitis. An increased number of cases were reported after implementation, i.e., 11 compared to the retrospective records of 5 patients. Nurses perceived a benefit for their patients and reported good nursing practices after the intervention. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA rigorous oral care regimen alone cannot reduce the incidence of severe oral mucositis in patients with HNC receiving chemoradiotherapy. Regular dental care programs may indirectly help enhance treatment compliance by lowering the risk of infection. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. According to our findings, a specific oral hygiene regimen reduced the development of mucositis and was negatively correlated with opportunistic infections. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The progress of existing knowledge toward the common goal of improved patient outcomes shared by healthcare professionals is facilitated by the use of many types of evidence in developing an organized plan of care for oral mucositis among patients with cancer. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Applying best practices in four hematology\u0026ndash;oncology contexts is feasible for improving oral mucositis prevention and therapy for cancer patients. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, there are limitations inherent to the present study. The sample was representative of cancer patients who met the inclusion criteria mentioned in the study. The researchers could not observe the practice of the oral care intervention, as it was difficult for the researcher to be present throughout the intervention. Only verbal reports of the continuity of oral care by the patients and their relatives were collected during each visit concerning adherence to the protocol. In addition, the researchers and participants were not blinded to the intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOral complications are the most common post-radiation therapy/chemotherapy-associated complications and may cause significant morbidity and mortality. A combined effort by multiple professionals, such as medical oncologists, radiation oncologists, oral medicine specialists, and oncology nurses, can result in the development of simple yet effective patient care interventions, including specific oral care protocols and oral care kit interventions for oral care of cancer patients receiving head and neck radiation/chemoradiation. An oral care intervention protocol effectively delays the incidence of oral complications such as oral mucositis, chewing difficulty, and swallowing difficulty but does not prevent these complications. However, the incidence of complications such as oral candida infection, speaking difficulty, bleeding gums, xerostomia, taste loss, and nutritional imbalance did not significantly differ, indicating that treatment was ineffective for these oral complications. Significant mean and median differences in the incidence of oral complications were detected between the intervention and control groups. These data suggest that the oral care intervention protocol is clinically valuable for maintaining overall oral health among cancer patients receiving head and neck radiation/chemoradiation. The findings of this study can also contribute to justifying the use of an oral care kit, including all evidence-based interventions for patients receiving head and neck radiation/chemoradiation, which is potentially useful for future comparisons.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding \u003cstrong\u003eDeclaration\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNo funds received\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eRRP: concept, design, the definition of intellectual content, literature search, clinical studies, experimental studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review. RO: concept, design, the definition of intellectual content, clinical studies, experimental studies, manuscript preparation, manuscript editing, and manuscript review. SB: concept, design, the definition of intellectual content, clinical studies, manuscript editing, and manuscript review. LSG: clinical studies, manuscript editing, and manuscript review. AG: clinical studies, manuscript editing, and manuscript review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEpstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, et al. Oral complications of cancer and cancer therapy: from cancer treatment to survivorship. CA: a cancer journal for clinicians. 2012;62(6):400\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosel D, Bauer R, Lynch D, Hwang S. Oral complications in the treatment of cancer patients. Oral diseases. 2011;17(6):550\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang T-J, Mu P-F, Chen M-B, Florczak K. Prevention and treatment of oral mucositis among cancer patients in the hematology\u0026ndash;oncology setting: a best practice implementation project. JBI Evidence Implementation. 2020;18(4):420\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLalla RV, Treister N, Sollecito T, Schmidt B, Patton LL, Mohammadi K, et al. Oral complications at 6 months after radiation therapy for head and neck cancer. Oral diseases. 2017;23(8):1134\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRinkel RN, Verdonck-de Leeuw IM, Doornaert P, Buter J, de Bree R, Langendijk JA, et al. Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI. European Archives of Oto-Rhino-Laryngology. 2016;273:1849\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussi EG, Corv\u0026ograve; R, Merlotti A, Alterio D, Franco P, Pergolizzi S, et al. Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology. Cancer treatment reviews. 2012;38(8):1033\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer medicine. 2017;6(12):2918\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobs JM, Ream ME, Pensak N, Nisotel LE, Fishbein JN, MacDonald JJ, et al. Patient experiences with oral chemotherapy: adherence, symptoms, and quality of life. Journal of the National Comprehensive Cancer Network. 2019;17(3):221\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStark LL, Tofthagen C, Visovsky C, McMillan SC. The symptom experience of patients with cancer. Journal of Hospice \u0026amp; Palliative Nursing. 2012;14(1):61\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanHoose L, Black LL, Doty K, Sabata D, Twumasi-Ankrah P, Taylor S, et al. An analysis of the distress thermometer problem list and distress in patients with cancer. Supportive care in cancer. 2015;23:1225\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng KKF. Oral mucositis, dysfunction, and distress in patients undergoing cancer therapy. 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Archives of Medical Science. 2014;10(6):1153\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElad S, Raber-Durlacher JE, Brennan MT, Saunders DP, Mank AP, Zadik Y, et al. Basic oral care for hematology\u0026ndash;oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT). Supportive Care in Cancer. 2015;23(1):223\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong CHL, Gueiros LA, Fulton JS, Cheng KKF, Kandwal A, Galiti D, et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guidelines. Supportive Care in Cancer. 2019;27(10):3949\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePai RR, Ongole R. Nurses\u0026rsquo; knowledge and education about oral care of cancer patients undergoing chemotherapy and radiation therapy. Indian journal of palliative care. 2015;21(2):225.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper D, Kim J, Duderstadt K, Stewart R, Lin B, Alkon A. Interprofessional oral health education improves knowledge, confidence, and practice for pediatric healthcare providers. Frontiers in Public health. 2017;5:209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen EE, LaMonte SJ, Erb NL, Beckman KL, Sadeghi N, Hutcheson KA, et al. American Cancer Society head and neck cancer survivorship care guideline. CA: a cancer journal for clinicians. 2016;66(3):203\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn BG, Campbell F, Fulman L, Harding J, Dargan S, Mathlin J, et al. Oral care of patients in the cancer setting. Cancer Nursing Practice. 2023;22(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy\u0026ndash;induced oral and gastrointestinal mucositis. Cancer: Interdisciplinary International Journal of the American Cancer Society. 2004;100(S9):2026\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein JB, Barasch A. Oral and dental health in head and neck cancer patients. Multidisciplinary Care of the Head and Neck Cancer Patient. 2018:43\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLalla RV, Saunders DP, Peterson DE. Chemotherapy or radiation-induced oral mucositis. Dental clinics. 2014;58(2):341\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoslemi D, Nokhandani AM, Otaghsaraei MT, Moghadamnia Y, Kazemi S, Moghadamnia AA. Management of chemo/radiation-induced oral mucositis in patients with head and neck cancer: A review of the current literature. Radiotherapy and Oncology. 2016;120(1):13\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaidu MUR, Ramana GV, Rani PU, Suman A, Roy P. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia. 2004;6(5):423\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRankin KV, Jones DL, Redding S. Oral health in cancer therapy. Tex Dent J. 2009;126(5):389\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadam P, Bhalerao S. Sample size calculation. International journal of Ayurveda research. 2010;1(1):55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health O. WHO handbook for reporting results of cancer treatment. Geneva: World Health Organization; 1979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn B. Addressing mouth care in cancer careecc_1164 526. European Journal of Cancer Care. 2009;18:526.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSieracki RL, Voelz LM, Johannik TM, Kopaczewski DM, Kelly Hubert R. Development and implementation of an oral care protocol for patients with cancer. Clinical journal of oncology nursing. 2009;13(6):718.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroadfield L. Best Practice Guidelines for the Management of Oral Complications from Cancer Therapy: Quick Reference Version: Cancer Care Nova Scotia; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCullen L, Baumler S, Farrington M, Dawson C, Folkmann P, Brenner L. CE: Oral Care for Head and Neck Cancer Symptom Management. AJN The American Journal of Nursing. 2018;118(1):24\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaito H, Watanabe Y, Sato K, Ikawa H, Yoshida Y, Katakura A, et al. Effects of professional oral health care on reducing the risk of chemotherapy-induced oral mucositis. Supportive Care in Cancer. 2014;22(11):2935\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNikoletti S, Hyde S, Shaw T, Myers H, Kristjanson LJ. Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of clinical nursing. 2005;14(6):750\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaplinger JRNMSAOCN, Royse MRNMSNC, Martens JRNBSNOCN. Implementation of an Oral Care Protocol to Promote Early Detection and Management of Stomatitis. Clinical Journal of Oncology Nursing. 2010;14(6):799\u0026ndash;802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokota T, Tachibana H, Konishi T, Yurikusa T, Hamauchi S, Sakai K, et al. Multicenter phase II study of an oral care program for patients with head and neck cancer receiving chemoradiotherapy. Supportive Care in Cancer. 2016;24(7):3029\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoneda S, Imai S, Hanada N, Yamazaki T, Senpuku H, Ota Y, et al. Effects of oral care on development of oral mucositis and microorganisms in patients with esophageal cancer. Japanese journal of infectious diseases. 2007;60(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEilers J, Million R. Clinical Update: Prevention and Management of Oral Mucositis in Patients with Cancer. Seminars in Oncology Nursing. 2011;27(4):e1-e16.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4534806/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4534806/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHead and neck cancer patients receiving chemotherapy and radiation therapy may experience a notable and frequently sudden decline in their oral health. These alterations include oral mucositis that develops during and shortly after treatment, candida infections, trouble speaking, difficulty eating, bleeding gums, and tissue fibrosis.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003e The study aimed to determine the effectiveness of oral care protocol intervention on oral health and oral complications. These patients were observed every week for up to 6 weeks until the completion of radiation therapy/chemoradiation. An experimental design using a Randomized Controlled Trial was adopted for the study. After obtaining the informed consent, the data were collected from 80 head and neck cancer patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe majority, i.e., 51.2%, were in the experimental group, and 52.5% were in the age group of 56 years and above. Most patients were males, 92.5% in the experimental group and 87.5% in the control group. A maximum number of the patients, i.e., 42.5% in the experimental group and 32.5% in the control group, were diagnosed to have tongue cancer. Regarding the treatment details of the participants, most of the participants, i.e., 57.5% in the experimental group and 67.5% in the control group, received chemoradiation as the treatment plan. Among all the oral complications, the median days to develop mucositis (p\u0026thinsp;=\u0026thinsp;.015), taste loss (p\u0026thinsp;=\u0026thinsp;.028), swallowing difficulty (p\u0026thinsp;=\u0026thinsp;.004), infection (p\u0026thinsp;=\u0026thinsp;.017), xerostomia (p\u0026thinsp;=\u0026thinsp;.004) and bleeding gums (p\u0026thinsp;=\u0026thinsp;.025) were statistically significant in comparison with control, indicating that the intervention was effective. As treatment progressed, the severity of these structural changes and functional activities increased in both groups. Over the weeks, the severity of the oral problems increased in both groups (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Compared to the standard of oral care, oral care intervention improved oral health among cancer patients receiving radiation therapy/chemoradiation. The findings of this study can also contribute to justifying the evidence for using an oral care protocol for head and neck cancer patients.\u003c/p\u003e","manuscriptTitle":"Effect of the Oral Care Intervention Protocol (OCIP) on the Oral Health Scores of Head and Neck Cancer Patients Receiving Radiation/Chemoradiation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:04:00","doi":"10.21203/rs.3.rs-4534806/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f5ebad5-dc60-4f4a-8eb8-da6263cb172c","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-21T05:10:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 16:04:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4534806","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4534806","identity":"rs-4534806","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}