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Postradiation trismus and its impact on quality of life in patients with head and neck cancer: a commentary
Vol. 121 No. 2 February 2016
LETTERS TO THE EDITOR Postradiation trismus and its impact on quality of life in patients with head and neck cancer: a commentary To the Editor: We read with great interest the recently published article by Lee et al., titled “Postradiation trismus and its impact on quality of life in patients with head and neck cancer.” Results from the study indeed indicate the various factors related to trismus in patients with head and neck cancer and highlight the need for establishment of prevention and rehabilitation programs for such patients. The authors have commendably enumerated various limitations in their study and also given recommendations for further studies in this field. However, there are a few issues in the article of which we would appreciate if the authors could provide further clarifications. 1. It has been stated by the authors1 that the sample included predominantly oral cavity cancer (54.9%) and nasopharyngeal carcinoma (18.6%), reflecting the usual distribution of head and neck cancers in Taiwan. However, we could not comprehend the same information from the data provided and there is quite a disparity in the percentage of the same demographic characteristics provided in Table I. 2. Trismus in head and neck cancer can be due to various reasons. Tumors affecting nasopharyngeal region and retromolar trigone are known to cause trismus as a result of the tumor extension to the muscles of mastication. Because a majority of cancer cases in the present study affect those areas (55 out of 104), preradiation and postradiation measurements of the mouth opening and its comparison could have been performed to objectively ascertain therapeutic radiation as the cause of trismus and avoided the ambiguity. 3. It is not very convincing how trismus is attributed as the reason for developing depression in these patients because we believe it is multifactorial. The very fact that they are affected by cancer, other comorbidities, or financial constraints can be extremely depressing, and this again could have been substantiated only by preradiotherapy psychological assessment of the patients using relevant psychometric questionnaires and comparing this with post-treatment status.2 We take this opportunity to record our appreciation of the efforts put forth by authors in conducting this 196
Table I. Demographic characteristics of patients and disease treatmenterelated characteristics (n ¼ 104) Variable Age >65 64-40 <40 Gender Male Female Occupation Unemployed Employed Marital status Unmarried Married Education level None Elementary Junior high Senior high College and above Religion None Buddhism/Taoism Christianity/Catholicism Pathologic cancer stage I II III IV Cancer site Nasopharynx Oral cavity Oropharynx Hypopharynx Larynx Type of treatment RT CCRT History of chewing betel nut No Yes History of smoking No Yes History of alcohol used No Yes Radiotherapy (total dose, centigray) Time since completion of RT (months) Performance status (level) 70 80 90 100
Number (%)
Mean (SD) 54.8 (14.0)
32 (30.8) 61 (58.7) 11 (10.6) 96 (92.3) 8 (7.7) 51 (49.0) 53 (51.0) 4 (3.8) 100 (96.2) 15 13 23 36 17
(14.4) (12.5) (22.1) (34.6) (16.3)
10 (9.6) 93 (89.4) 1 (1.0) 26 16 33 29
(25.0) (15.4) (31.7) (27.9)
55 11 15 17 6
(52.9) (10.6) (14.4) (16.4) (5.8)
34 (32.7) 70 (67.3) 67 (64.4) 37 (35.6) 46 (44.2) 58 (55.8) 51 (49.0) 53 (51.0) 6703.3 (545.1) 12.5 (6.2)
9 3 23 69
(8.6) (2.9) (22.1) (66.3)
RT, radiation therapy; CCRT, concurrent chemotherapy and radiation therapy.
OOOO Volume 121, Number 2
study with a view to contributing to enhanced quality of life over the long term in cancer patients. Divyansh Bansal, BDS Postgraduate Student Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India Ravindranath Vineetha, MDS Associate Professor Department of Oral Medicine and Radiology Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India
LETTERS TO THE EDITOR
197
anterior region seems to be merely hypothetical. If there were an associated lesion, the finding could then have been considered incidental. We believe that a photograph of the scan would be appreciated by the readers. The authors also mention a lower permanent canine as an incidental finding in these scans. We do not understand how a lower permanent canine can be found in the scan taken for the upper anterior region. It would be interesting to know the authors’ opinion on these issues. Kaustubh Sansare, BDS, MDS Associate Professor Oral Medicine and Radiology Nair Hospital Dental College Mumbai, India
Keerthilatha M. Pai, MDS Professor and Head Department of Oral Medicine and Radiology Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India
Freny Karjodkar, BDS, MDS Professor and Head Oral Medicine and Radiology Nair Hospital Dental College Mumbai, India
REFERENCES 1. Lee LY, Chen SC, Chen WC. Post radiation trismus and its impact on quality of life in patients with head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:187-195. 2. Pauli N, Johnson J, Finizia C, Andrell P. The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer. Acta Oncol. 2013;52:1137-1145.
REFERENCE
http://dx.doi.org/10.1016/j.oooo.2015.06.042
http://dx.doi.org/10.1016/j.oooo.2015.08.023
Incidental observations on “Clinical importance of incidental findings reported on smallvolume dental cone beam computed tomography scans focused on impacted maxillary canine teeth” To the Editor: We read with interest the article “Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth” by DogramacI EJ et al.1 We appreciate the authors’ extensive work on the incidental findings on small fields of view. Table 1 of the article mentions impacted teeth as a category of incidental findings. The authors mention third permanent molars as an incidental finding. However, it is not clear how a third permanent molar can be seen in a scan taken for an impacted maxillary canine. Without any associated lesion, the suggestion that a maxillary third molar is impacted in the maxillary
1. DogramacI EJ, Rossi-Fedele G, McDonald F. Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118: e205-e209.
Response to letter to editor To the Editor: We would like to take this opportunity to thank Drs. Sansare and Karjodkar for their letter. Our retrospective study “.identified the radiologic reports of patients who were referred for radiographic examination as part of the diagnosis and treatment planning for impacted or ectopically erupting maxillary canine teeth.”1 The definition of impaction was delivered in a previous article as “an impacted tooth is one which is unable to erupt as a result of either insufficient space in the dental arch, ectopic position of the tooth, or the presence of an obstruction such as a retained tooth, supernumerary or scar tissue.”2 An ectopic tooth is one that is in a different position from that which would normally be expected. This study relied on the radiology reports prepared for each patient by radiology consultants who are registered specialists in dental and maxillofacial radiology in the United Kingdom.1 In their letter, Drs. Sansare and Karjodkar have apparently made the erroneous assumption that a
LETTERS TO THE EDITOR Postradiation trismus and its impact on quality of life in patients with head and neck cancer: a commentary To the Editor: We read with great interest the recently published article by Lee et al., titled “Postradiation trismus and its impact on quality of life in patients with head and neck cancer.” Results from the study indeed indicate the various factors related to trismus in patients with head and neck cancer and highlight the need for establishment of prevention and rehabilitation programs for such patients. The authors have commendably enumerated various limitations in their study and also given recommendations for further studies in this field. However, there are a few issues in the article of which we would appreciate if the authors could provide further clarifications. 1. It has been stated by the authors1 that the sample included predominantly oral cavity cancer (54.9%) and nasopharyngeal carcinoma (18.6%), reflecting the usual distribution of head and neck cancers in Taiwan. However, we could not comprehend the same information from the data provided and there is quite a disparity in the percentage of the same demographic characteristics provided in Table I. 2. Trismus in head and neck cancer can be due to various reasons. Tumors affecting nasopharyngeal region and retromolar trigone are known to cause trismus as a result of the tumor extension to the muscles of mastication. Because a majority of cancer cases in the present study affect those areas (55 out of 104), preradiation and postradiation measurements of the mouth opening and its comparison could have been performed to objectively ascertain therapeutic radiation as the cause of trismus and avoided the ambiguity. 3. It is not very convincing how trismus is attributed as the reason for developing depression in these patients because we believe it is multifactorial. The very fact that they are affected by cancer, other comorbidities, or financial constraints can be extremely depressing, and this again could have been substantiated only by preradiotherapy psychological assessment of the patients using relevant psychometric questionnaires and comparing this with post-treatment status.2 We take this opportunity to record our appreciation of the efforts put forth by authors in conducting this 196
Table I. Demographic characteristics of patients and disease treatmenterelated characteristics (n ¼ 104) Variable Age >65 64-40 <40 Gender Male Female Occupation Unemployed Employed Marital status Unmarried Married Education level None Elementary Junior high Senior high College and above Religion None Buddhism/Taoism Christianity/Catholicism Pathologic cancer stage I II III IV Cancer site Nasopharynx Oral cavity Oropharynx Hypopharynx Larynx Type of treatment RT CCRT History of chewing betel nut No Yes History of smoking No Yes History of alcohol used No Yes Radiotherapy (total dose, centigray) Time since completion of RT (months) Performance status (level) 70 80 90 100
Number (%)
Mean (SD) 54.8 (14.0)
32 (30.8) 61 (58.7) 11 (10.6) 96 (92.3) 8 (7.7) 51 (49.0) 53 (51.0) 4 (3.8) 100 (96.2) 15 13 23 36 17
(14.4) (12.5) (22.1) (34.6) (16.3)
10 (9.6) 93 (89.4) 1 (1.0) 26 16 33 29
(25.0) (15.4) (31.7) (27.9)
55 11 15 17 6
(52.9) (10.6) (14.4) (16.4) (5.8)
34 (32.7) 70 (67.3) 67 (64.4) 37 (35.6) 46 (44.2) 58 (55.8) 51 (49.0) 53 (51.0) 6703.3 (545.1) 12.5 (6.2)
9 3 23 69
(8.6) (2.9) (22.1) (66.3)
RT, radiation therapy; CCRT, concurrent chemotherapy and radiation therapy.
OOOO Volume 121, Number 2
study with a view to contributing to enhanced quality of life over the long term in cancer patients. Divyansh Bansal, BDS Postgraduate Student Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India Ravindranath Vineetha, MDS Associate Professor Department of Oral Medicine and Radiology Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India
LETTERS TO THE EDITOR
197
anterior region seems to be merely hypothetical. If there were an associated lesion, the finding could then have been considered incidental. We believe that a photograph of the scan would be appreciated by the readers. The authors also mention a lower permanent canine as an incidental finding in these scans. We do not understand how a lower permanent canine can be found in the scan taken for the upper anterior region. It would be interesting to know the authors’ opinion on these issues. Kaustubh Sansare, BDS, MDS Associate Professor Oral Medicine and Radiology Nair Hospital Dental College Mumbai, India
Keerthilatha M. Pai, MDS Professor and Head Department of Oral Medicine and Radiology Manipal College of Dental Sciences Manipal University Manipal, Karnataka, India
Freny Karjodkar, BDS, MDS Professor and Head Oral Medicine and Radiology Nair Hospital Dental College Mumbai, India
REFERENCES 1. Lee LY, Chen SC, Chen WC. Post radiation trismus and its impact on quality of life in patients with head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:187-195. 2. Pauli N, Johnson J, Finizia C, Andrell P. The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer. Acta Oncol. 2013;52:1137-1145.
REFERENCE
http://dx.doi.org/10.1016/j.oooo.2015.06.042
http://dx.doi.org/10.1016/j.oooo.2015.08.023
Incidental observations on “Clinical importance of incidental findings reported on smallvolume dental cone beam computed tomography scans focused on impacted maxillary canine teeth” To the Editor: We read with interest the article “Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth” by DogramacI EJ et al.1 We appreciate the authors’ extensive work on the incidental findings on small fields of view. Table 1 of the article mentions impacted teeth as a category of incidental findings. The authors mention third permanent molars as an incidental finding. However, it is not clear how a third permanent molar can be seen in a scan taken for an impacted maxillary canine. Without any associated lesion, the suggestion that a maxillary third molar is impacted in the maxillary
1. DogramacI EJ, Rossi-Fedele G, McDonald F. Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118: e205-e209.
Response to letter to editor To the Editor: We would like to take this opportunity to thank Drs. Sansare and Karjodkar for their letter. Our retrospective study “.identified the radiologic reports of patients who were referred for radiographic examination as part of the diagnosis and treatment planning for impacted or ectopically erupting maxillary canine teeth.”1 The definition of impaction was delivered in a previous article as “an impacted tooth is one which is unable to erupt as a result of either insufficient space in the dental arch, ectopic position of the tooth, or the presence of an obstruction such as a retained tooth, supernumerary or scar tissue.”2 An ectopic tooth is one that is in a different position from that which would normally be expected. This study relied on the radiology reports prepared for each patient by radiology consultants who are registered specialists in dental and maxillofacial radiology in the United Kingdom.1 In their letter, Drs. Sansare and Karjodkar have apparently made the erroneous assumption that a