Abstract
The purpose of this study was to investigate how patients with maxillofacial defects evaluate their quality of life after maxillectomy and prosthodontic therapy with obturator prostheses. 43 patients were included in the study (25 female, 18 male). 31 (72%) patients completed a standardized questionnaire of 143 items and then answered additional questions in a standardized interview. Global quality of life after prosthodontic therapy with obturator prostheses was 64% (±22.9) on average. Functioning of the obturator prosthesis, impairment of ingestion, speech and appearance, the extent of therapy, and the existance of pain had significant impact on the quality of life ( p < 0.005). Orofacial rehabilitation of patients with maxillofacial defects using obturator protheses is an appropriate treatment modality. To improve the situation of patients prior to and after maxillectomy sufficient information about the treatment, adequate psychological care and speech therapy should be provided.
Quality of life is an important consideration in philosophy, medicine, religion and also in ecomomics and politics. In general, the term ‘quality of life’ is used to describe factors that influence the living conditions of a society or of the society’s individuals. The WHO defines quality of life as ‘the individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ . Quality of life also includes physical health, personal circumstances (wealth, living conditions), social relationships, functional activities and pursuits, as well as wider societal and economic influence .
Traditionally, end points such as recurrence rates and survival have been used to evaluate the outcome of therapeutic interventions in head and neck cancer while patient’s satisfaction or quality of life is not usually considered. Recently, the recognition of the multidimensional impact of maxillofacial tumors on a patient’s life has led to an increased interest in the quality of life of these patients . Significant studies investigating the quality of life of patients with maxillofacial defects after prosthodontic therapy with obturator prostheses remain rare ( Table 1 ). Until now, little data has been published dealing with the comparison between prosthetic obturation and (free flap) reconstruction .
| Author | Journal/year | Total patients | Questionnaires | Results |
|---|---|---|---|---|
| K ornblith et al. | Head Neck 1996 | 47 Obturation | Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR) | Satisfactory functioning of the obturator prosthesis was |
| Quality of life of maxillectomy patients using an obturator prosthesis | Mental Helath Inventory (MHI) | (1) The most highly significant predictor of adjustment, and | ||
| Impact on Event Scale (IES) | (2) Significantly related to the perception of the negative socioeconomic impact of cancer upon their lives. | |||
| The Family Functioning Scale | The most significant predictor of better obturator functioning was the extent of resection of the soft and hard palate. | |||
| Obturator Functioning Scale (OFS) | Specific aspects of obturator functioning that most significantly correlated with better adjustment were: less difficulty in pronouncing words, chewing and swallowing and less change in their voice quality after surgery. | |||
| Perceived Negative Socioeconomic Impact on Cancer Index | ||||
| B orlase | Ann R Australas Coll Dent Surg 2000 | 13 Obturation from Greenlane | Obturator Functioning Scale (OFS) | Patients of both groups favoured the use of an obturator which successfully managed the functional and aesthetic concerns. |
| Use of obturators in rehabilitation of maxillectomy defects | 47 Control (Obturation from Memorial- Sloane-Kettering) | |||
| B rown et al. | Head Neck 2000 | Class 1 and 2a | University of Washington Head and Neck Questionnaire (UW-QOL) | No significant differences were found between the method of rehabilitation in each group. |
| A modified classification for the maxillectomy defect | 8 Obturation | A significant lower cumulative score between class 1 and 2a defects compared to class 2b plus was observed. Although speech and chewing scored lower (but not significant) averages for the larger defects disfigurement, swallowing, and shoulder function showed similar results. | ||
| 8 Reconstruction | ||||
| Class 2b plus | ||||
| 3 Obturation | ||||
| 11 Reconstruction | ||||
| R ieger et al. | Head Neck 2003 | 20 Obturation | Obturator Functioning Scale (OFS) | Poorer aeromechanical speech results were associated with patient-reported avoidance of social events. |
| Maxillary obturators: the relationship between patient satisfaction and speech outcome | Nasometer (PERCI-SARS, Computerized Assessment of Intelligibility of Dysarthric Speech (C-AIDS) program) | Lower speech intelligibility outcomes were related to overall poorer perception of speech function on the OFS. | ||
| R ogers et al. | J Oral Maxillofac Surg 2003 | 28 Obturation | University of Washington Head and Neck Questionnaire (UW-QOL) | No statistically significant differences were seen between the obturator and free flap groups. Borderline trends were for obturator patients to be more concerned about their appearance, to have more pain and soreness in their mouths, to be more aware of their upper teeth, more self-conscious and less satisfied with their upper dentures, and less satisfied with function |
| Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap | 18 Free tissue transfer | |||
| European Organization for Research and Treatment of Cancer Core QOL Questionnaire (EORTC QLQ C30) | ||||
| EORTC Head and Neck | ||||
| Hospital Anxiety Depression (HAD) | ||||
| Body satisfaction Scale (BSS) | ||||
| Oral Symptom Check List | ||||
| Denture Satisfaction | ||||
| Obturator Functioning Scale (OFS) | ||||
| H ertrampf et al. | Int J Prosthodont 2004 | 17 Obturation | European Organization for Research and Treatment of Cancer Core QOL Questionnaire (EORTC QLQ C30) | No significant differences between tumor patients and nontumor patients regarding global quality of life. However, tumor patients had significantly more impairment of function. |
| Quality of life of patients with maxillofacial defects after treatment for malignancy | 17 Control (nontumor group) | EORTC Head and Neck module EORTC QLQ HN35) | In comparison with the reference data of the German population, tumor patients had some considerable deficits. | |
| Cantril Scale for measurement of Quality of life | When reflecting the course of disease and recovery, tumor patients rated the diagnosis as the most stressful event and reported that the family was most instrumental in the recovery process. | |||
| I rish et al. | Head Neck 2009 | 42 Obturation | Obturator Functioning Scale (OFS) | Maxillectomy patients compared favorably with other patients with head and neck cancer as well as other disease populations, both in terms of levels of depression and illness intrusiveness. Leakage when swallowing foods was the most frequently reported problem with the obturator. Difficulty with speech and eating was associated with increased avoidance of social situations. |
| Quality of life in patients with maxillectomy prostheses | Mental Helath Inventory (MHI) | |||
| Illness Intrusiveness Ratings Scale (IIRS) | ||||
| Centre for Epidemiologic Studies Depression Scale (CES-D) | ||||
| Impact of Events Scale (IES) |
Microvascular free tissue transfer techniques have become established in recent years, but the optimal reconstruction of maxillectomy defects remains controversial. The decision whether to reconstruct or to obturate depends on patient characteristics such as age, medical history, and defect size and on the surgeon’s technical expertise . Surgical flap reconstruction provides definitive correction of the abnormal oronasal communication, and, in general is associated with increased procedure time and the possibility of donor morbidity at the flap harvest site . In contrast, fabrication of obturator prostheses shortens the procedure time and offers the possibility of immediate and adequate dental rehabilitation. The surgical site can be easily examined after removing the obturator prosthesis, and tumor recurrence may be detected in time . Obturation may therefore still be the privileged treatment modality after maxillectomy and explain why studies comparing both patient groups (obturator vs. free flaps) are rare.
The most important aspects of treatment after resection of the maxilla are to reconstruct the maxillary defects and restore oronasal functions and facial contours. In general, obturator prostheses comply with these requirements but patients’ difficulties in handling the obturator prosthesis or impaired obturator functioning may lead to deficits in speech, mastication, swallowing or facial disfigurement, and as a consequence, patient dissatisfaction . Although free flap transfer aims to deal with these problems that are often associated with obturator prostheses (e.g. hypernasal speech, foods and liquids escaping through the nasal cavity) no statistically significant differences between prosthetic obturation and free flap could be detected .
Table 1 indicates that most studies investigating the quality of life used more than one questionnaire. The aim of the present study was to evaluate the quality of life of patients with maxillofacial defects after prosthodontic therapy with obturator prostheses using the detailed DOESAK questionnaire. The hypothesis was that the patients’ quality of life after obturation is acceptable compared to the quality of life of the normal population.
Methods
All patients who received maxillary resection and prosthodontic therapy with definite obturator prostheses from January 2000 to December 2005 were included in the cross-sectional study. The study was approved by the department of the university (consistent with institutional review board approval). All patients provided written informed consent prior to their participation in the study. Patients younger than 18 years, with temporary obturator prosthesis or whose therapy had been carried out within the past 6 months were excluded from the study. All obturator prostheses were fabricated in the authors’ department.
Eligible patients were sent a standardized questionnaire and telephone interviews were conducted by a single trained interviewer (D.L.). The study sample consisted of 31 (72%) of the 43 eligible patients; 6 had died and another 6 were not available.
The 143 questions asked were based on a questionnaire originally developed for DOESAK (a German, Austrian and Swiss cooperative group on tumors of the maxillofacial region) . The detailed questionnaire was adjusted for obturator patients and internalized most parts of the well established EORTC QLQ-H&N35 and the Obturator Functioning Scale (OFS). The nine main domains of the DOESAK questionnaire contained among others: course of disease before hospital stay and surgery; course of disease after surgery; follow-up care; specific problems due to surgery and/or radiation therapy; handling of disease; and personal living conditions and habits. The questions related to specific problems due to surgery and/or radiation therapy such as pain, speech problems, senses problems, trouble with social eating, appearance and dry mouth. Most questions were multiple choice. A five-point Likert scale and a centigrade scale (0 = dissatisfied, 100 = satisfied) were used for quantifying changes in the quality of life.
The data were processed with SPSS ® 16.0 for windows statistical software (SPSS Inc., Chicago, IL, USA). Quality of life scores were computed and normal distribution of quantitative variables was verified by the use of the Shapiro-Wilk Test. Cases of normal distribution differences in prevalences between groups were tested with Student’s t -test, otherwise Kruskal–Wallis one-way analysis of variance or Scheffé’s method were applied for the analysis of the quantitative variables. Evaluation of nominal and ordinal data was performed using Pearson’s χ 2 test and Fisher’s exact test. Kendall tau rank correlation coefficient was calculated to measure the strength of association of the cross tabulations. For all statistical analyses probability levels of p < 0.05 were considered statistically significant. As the aim of the present study was not to test an overall null hypothesis Bonferroni adjustment was not used .
Results
The sociodemographic and medical characteristics of the 31 patients interviewed are given in Table 2 . The 17 (55%) female and 14 (45%) male patients were a mean of 67.6 years old (SD = 10.7, range 34–82 years) and predominantly had basic secondary school education (55%, 17/31). Most participants (55%, 17/31) had retired before they underwent maxillary resection, 19% (6/31) retired or lost their job as a consequence of the disease and 26% (8/31) remained in employment.
| Patient characteristics ( n = 31) | N (%) |
|---|---|
| Gender | |
| Male | 14 (45.2%) |
| Female | 17 (54.8%) |
| Age in years | |
| Mean | 67.6 (±10.7) |
| Range | 34–82 |
| 30–39 | 1 (3.2%) |
| 40–49 | 3 (9.7%) |
| 50–59 | 2 (6.5%) |
| 60–69 | 13 (41.9%) |
| 70–79 | 9 (29.0%) |
| 80–89 | 3 (9.7%) |
| Marital status | |
| Single | 3 (9.7%) |
| Married | 22 (70.9%) |
| Divorced | 4 (12.9%) |
| Widowed | 2 (6.5%) |
| Educational status | |
| No graduation | 2 (6.5%) |
| Basic secondary school | 17 (54.8%) |
| Secondary school level I certificate | 9 (29.0%) |
| University- or technical college entrance diploma | 3 (9.7%) |
| Employment status | |
| Retired | 23 (74.2%) |
| Not retired | 8 (25.8%) |
| Tumor type | |
| Squamous cell carcinoma | 16 (51.6%) |
| Adeno carcinoma | 6 (19.4%) |
| Adenoid cystic carcinoma | 3 (9.7%) |
| Mucoepidermoid carcinoma | 1 (3.2%) |
| Ameloblastoma | 1 (3.2%) |
| Other | 4 (12.9%) |
| Therapy | |
| Surgery | 21 (67.7%) |
| Surgery + radiation therapy | 7 (22.6%) |
| Surgery + radiation + chemo therapy | 3 (9.7%) |
| Smoking before tumor treatment | |
| Yes | 23 (74.2%) |
| No | 8 (25.8%) |
| Smoking after tumor treatment | |
| Yes | 3 (9.7%) |
| No | 28 (90.3%) |
| Alcohol before tumor treatment | |
| No | 6 (19.35%) |
| Sometimes | 19 (61.2%) |
| Daily | 6 (19.35%) |
| Alcohol after tumor treatment | |
| Less | 12 (38.8) |
| Unchanged | 19 (61.2%) |
Patients received maxillary surgery at a mean age of 59 (±12.1) years. The most frequent histological diagnoses were squamous cell carcinoma (52%, 16/31), adenocarcinoma (19%, 6/31) and adenoid cystic carcinoma (10%, 3/31).
Before they received tumor treatment 74% (23/31) of patients smoked cigarettes, 19% (6/31) of patients consumed alcohol regularly, 61% (19/31) consumed it sometimes and 19% (6/31) reported no alcohol consumption. After diagnosis or treatmeant of maxillary disease, 20 patients gave up smoking and 12 reduced their alcohol consumption ( Table 2 ).
The global quality of life after prosthodontic therapy with obturator prosthesis was found to be 64% (±22.9) on average. Lowest ratings (57%) were observed in patients aged 60–69 years ( n = 13), compared with patients in all other age groups ( Table 3 ). Female patients evaluated their quality of life slightly better than male patients (female 65%, male 64%). Quality of life of obturator patients was not significantly related to age (Kendall tau, τ = −0.031, p = 0.828), and gender ( t -test, p = 0.092) or size of tumor (Kruskal–Wallis p = 0.123) in contrast to existence of pain ( t -test p = 0.002). Significant impact on the quality of life was linked to level of education (ANOVA, p = 0.013). Patients with the highest level of education rated their quality of life significantly higher compared with patients with little education (Scheffé, p = 0.031). The extent of therapy also correlated positively with the quality of life. A significantly better average rating was found when patients had received surgery only compared with patients whose treatment had consisted of surgery plus radiation and chemotherapy (Scheffé, p = 0.042). Neither the classification of maxillary defects (ANOVA, p = 0.793), nor the type of surgery (transoral vs. transfacial) ( t -test, p = 0.569) had a significant influence on the patients’ evaluation of their quality of life ( Table 3 ).
| Item scales | N (%) | Quality of life Mean (SD, Min, Max) | Significant correlations |
|---|---|---|---|
| All patients | 31 (100) | 64.4% (±22.9, 10, 100) | |
| Gender | |||
| Male | 14 (45.2) | 63.6% (±23.2, 20, 100) | p = 0.092 |
| Female | 17 (54.8) | 65.0% (±23.2, 10, 100) | |
| Age | |||
| 30–39 | 1 (3.2) | 95.0% | τ = −0.031 |
| 40–49 | 3 (9.7) | 65.0% (±25.0, 40, 90) | p = 0.828 |
| 50–59 | 2 (6.5) | 80.0% (±14.1, 70, 90) | |
| 60–69 | 13 (41.9) | 56.2% (±27.3, 10, 100) | |
| 70–79 | 9 (29.0) | 70.6% (±15.7, 50, 100) | |
| 80–89 | 3 (9.7) | 60.0% (±17.3, 50, 80) | |
| Educational status | |||
| No graduation | 2 (6.5) | 30.0% (±28.3, 10, 50) | p = 0.013 |
| Basic secondary school | 17 (54.8) | 59.1% (±19.6.4, 20, 100) | |
| Secondary school level I certificate | 9 (29.0) | 72.2% (±20.3, 40, 95) | |
| University- or technical college entrance diploma | 3 (9.7) | 85.0% (±15.8, 65, 100) | |
| Stage of disease | |||
| T1 | 3/27 (11.1) | 91.7% (±2.9, 90, 95) | p = 0.123 |
| T2 | 13/27 (48.2) | 56.2% (±24.1, 10, 100) | |
| T3 | 6/27 (22.2) | 65.0% (±25.1, 40, 100) | |
| T4 | 5/27 (18.5) | 59.0% (±17.5, 40, 80) | |
| Existence of pain | |||
| Yes | 15 (48.4) | 52.0% (±20.5, 10, 80) | p = 0.002 |
| No | 16 (51.6) | 75.9% (±18.9, 40, 100) | |
| Therapy | |||
| Surgery | 20 (64.5) | 70.8% (±18.9, 40,100) | p = 0.042 |
| Surgery + radiation therapy | 7 (22.6) | 60.0% (±20.8, 40,100) | |
| Surgery + radiation + chemo therapy | 4 (12.9) | 40.0% (±31.6, 10, 80) | |
| Type of surgery | |||
| Transoral | 18 (58.1) | 66.4% (±23.1, 20, 100) | p = 0.569 |
| Transfacial | 13 (41.9) | 61.5% (±23.1, 10, 100) | |
| Defect class | |||
| I | 3 (9.7) | 56.7% (±11.5, 50, 70) | p = 0.793 |
| IIa | 12 (38.7) | 63.3% (±28.4, 10, 95) | |
| IIb | 9 (29) | 62.8% (±21.5, 40, 100) | |
| IIc | 1 (3.2) | 50% | |
| IIIa | 2 (6.5) | 70% (±28.8, 50, 90) | |
| IIIb | 3 (9.7) | 80% (±20, 60, 80) | |
| IIIc | – | ||
| IVa | – | ||
| IVb | 1 (3.2) | 70% | |
| IVc | – | ||
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