- Email: [email protected]
Understandability of Speech Predicts Quality of Life Among Maxillectomy Patients Restored With Obturator Prosthesis
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CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Understandability of Speech Predicts Quality of Life Among Maxillectomy Patients Restored With Obturator Prosthesis Q9
Crystianne Pacheco Seignemartin, DDS,* Milton E. Miranda, DDS, MS, PhD,y Jo~ ao Gualberto C. Luz, DDS, MS, PhD,z and Rubens G. Teixeira, DDS, MS, PhDx Purpose:
Maxillary malignant tumor resection by maxillectomy might lead to defects that can be repaired by prosthetic obturation. The aim of this study was to associate quality of life (QoL) and the Obturator Functioning Scale (OFS) with functional performance and salivary flow rate in Brazilian patients rehabilitated with an obturator prosthesis.
Patients and Methods:
This retrospective cross-sectional study included patients who underwent surgical resection with or without radiotherapy without or without chemotherapy and the rehabilitation with an obturator prosthesis at the Fundac¸~ao Oncocentro de S~ao Paulo (S~ao Paulo, Brazil). The predictor variables were Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) domains and clinical evaluation of salivary flow rate. The outcome variables were overall scores obtained by the University of Washington QoL Scale (UWQOL) and the OFS. Sociodemographics (gender and age) and clinical characteristics (postoperative radiotherapy, tumor stage, classification of maxillary defect, tooth in maxilla, and type of obturator) also were evaluated. Univariate and multivariate analyses were performed to determinate whether PSS-HN domains and salivary flow were predictors of overall QoL and overall OFS.
Results:
The sample was composed of 73 patients with a mean age of 62 years and 51% were men. According to the PSS-HN domains, some patients (5%) always ate alone, 87% reported that speech is usually or always understandable, and 56% had no dietary restrictions. Sixty-one patients (65%) reported some degree of hyposalivation. The mean overall QoL score was 76.5 (standard deviation, 5.3). Patients with compromised PSS-HN domains had significantly worse overall UWQOL scores (P = .001, P < .001, and P = .006, respectively). In multiple regression analyses, understandability of speech was the only predictor of overall QoL scores.
Conclusion: Q3
Q2
The results of this study showed that understandability of speech was the only predictor of overall QoL scores. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2015 Oral cancer represents about 1 to 3% of all human cancers and is the sixth most frequent cancer worldwide. Ten percent of all oral cancers that occur in the oral cavity subsites of the upper gingiva and hard palate have similar clinical presentations and management because of their adjacent anatomies.1,2
Malignant tumors3 requiring maxillofacial surgeries4 can lead to defects caused by maxillectomy that result in serious esthetic and functional disabilities2-12 involving swallowing and speech.2,4-12 Maxillectomy defects can be repaired by prosthetic obturation or even reconstruction using free or microsurgical transplants, grafts, and distant or regional flaps.2,4,6,12-15
*Professor, Department of Maxillofacial Prosthodontics, Fundac¸~ao Oncocentro de S~ao Paulo, S~ao Paulo, Brazil.
S~ao Paulo, Rua Oscar Freire, 2396, 1 andar, S~ao Paulo, SP 05409-012,
Brazil; e-mail: [email protected]
yProfessor, Graduated Prosthodontic Department, School of
Received August 10 2014
Dentistry, S~ao Leoplodo Mandic, Campinas, Brazil. zFull Professor, Department of Oral and Maxillofacial Surgery,
Ó 2015 American Association of Oral and Maxillofacial Surgeons
School of Dentistry, University of S~ao Paulo, S~ao Paulo, Brazil.
0278-2391/15/00491-7
Accepted April 21 2015
xProfessor, Department of Surgery and Traumatology, School of
http://dx.doi.org/10.1016/j.joms.2015.04.031
Dentistry, S~ao Leopoldo Mandic, Campinas, Brazil. Address correspondence and reprint requests to Dr Seignemartin: Department of Maxillofacial Rehabilitation, Fundac¸~ao Oncocentro de
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2
SPEECH USING OBTURATOR PROSTHESIS
The extension of skin loss,4 the size of the defect,2,4,15 and the feasibility of having a team with a surgeon and a prosthodontist influence the method of reconstruction.4,13,15,16 However, an obturator prosthesis is still considered one of the most efficient rehabilitation tools in larger maxillary resections because it is fast, is low cost, has the possibility of modification according to the patients’ needs,6 an enhancement of intraoral functional, and the decrease of eventual cosmetic deformity by supplying missing teeth and supporting the lip and cheek.2 Recently, the recognition of the multidimensional effect of maxillofacial tumors on a patient’s quality of life (QoL) has led to increased interest.2,5,8-10,17-21 It has been proposed that QoL parameters should be assessed in addition to conventional clinical criteria21 to provide the clinician a choice from a variety of validated questionnaires22 and include them in the daily routine outcome parameter.17 Studies in the literature on QoL in patients with maxillectomy and rehabilitation with obturators5,7,8,10,11,14,16,21,23 have shown that the correlation between obturator function (Obturator Functioning Scale [OFS]) and QoL5,8,10,11,16,23 can be influenced by clinical factors, such as type of tumor and stage of disease, extent of the ablative defect, postoperative radiation therapy, number and condition of remaining maxillary teeth, and demographic and other social variables.5,8,14,16,23 To the best of the authors’ knowledge, studies of this kind of the Brazilian population are rare.6 After maxillectomy, patients can develop problems related to functional performance of eating and talking5,8,11,16 and xerostomia related to radiotherapy.2,10,24 There is a gap in the current literature associating this functional status (Performance Status Scale for Head and Neck Cancer Patients [PSS-HN])25 with QoL and obturator function. The purpose of this study was to evaluate whether functional performance of eating in public, understandability of speech, normalcy of diet, and salivary flow rate in patients with maxillectomy and rehabilitation with obturators are predictors of overall QoL and obturator function. The authors hypothesized that low functional performance25 and a low salivary flow rate4,7,14,16,23 would negatively influence the QoL and obturator function of these patients. The specific aims of the study were to associate clinical features and demographic variables with overall QoL and overall obturator functioning.
Patients and Methods STUDY DESIGN AND SAMPLE
This retrospective cross-sectional study was conducted at the Fundac¸~ao Oncocentro de Sao Paulo
(FOSP; S~ao Paulo, Brazil). From December 14, 2012 through February 14, 2013, the authors invited all patients who were treated at the maxillofacial rehabilitation department and were undergoing revision of their obturator prosthesis to participate in the study. Included were patients older than 18 years; men and women regardless of ethnicity; those treated for oral squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, or other tumors; and who underwent surgical resection with or without radiotherapy with or without chemotherapy and then rehabilitation with obturators. Patients were excluded as study subjects if they had tumor recurrence. This study was conducted after approval by the research ethics committee in humans in S~ao Leopoldo Mandic School of Dentistry (Campinas, Brazil) under protocol number 2012/0010 and by the FOSP supported by the Brazilian Department of Health to assist health policy on cancer in the state. VARIABLES
A QoL questionnaire for patients with head and neck cancer, The University of Washington QoL Scale (UWQOL; version 4); 2 performance measurements, the OFS and the PSS-HN; and clinical evaluation of salivary flow rate were used in this study. The questionnaires were given to the patients after signing an informed consent form. A single maxillofacial prosthodontist interviewer administrated all validated questionnaires and collected data on salivary flow. Outcome Variables Primary outcome—overall UWQOL score. This questionnaire is a self-administered scale consisting of 15 questions26 that is culturally appropriate and psychometrically valid in Brazilian Portuguese.24 The first 12 domains concern areas of daily living often affected by treatment of head and neck cancer, such as pain, disfigurement, activity, recreation and entertainment, chewing, swallowing, speech, shoulder disability, taste, saliva, and 2 new emotional domains of mood and anxiety. Outcome was determined by the accepted standard of an overall composite score.16 To describe current functional status, each domain has a maximum score of 100 points, indicating the highest level of function, and a minimum score of 0, indicating the poorest level of function. Secondary outcome—OFS score. This scale consists of 15 questions to measure patients’ ability to eat and speak with an obturator prosthesis and their satisfaction with the restoration of lip position and its cosmetic effects. Dryness of mouth, an effect of radiotherapy on major and possibly minor salivary glands, was included as an item in the scale because poor lubrication of the mouth is a possible contributor to
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Q1
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poorer fit or functioning of the prosthesis.11 Another item, ‘‘difficulty talking on the phone,’’ was added to the scale to assess communication difficulties in the absence of visual cues.5 The answer to each question is rated in a numerical value from 0 to 100. A score of 0 indicates maximum suffering or dissatisfaction and a score of 100 indicates that the patient was asymptomatic or extremely satisfied in the respective domain.16 Predictor Variables Primary predictor—PSS-HN score. This questionnaire was designed to evaluate the performance of functions most likely to be affected by head and neck cancer and eating in public. It is a clinicianrated instrument consisting of 3 scales: normalcy of diet, understandability of speech, and eating in public. The 3 areas of function are rated from 100 to 0, with a score of 100 representing no dysfunction.25 Secondary predictor—Measurement of salivary flow. To objectively establish a patient’s perception of saliva flow that featured xerostomia, the volumetric method was chosen,27-30 in which quantitative gravimetric sialometry using a taste stimulus (2 drops of 2% citric acid) measured the absorption of saliva by cotton rolls, which were weighed on a precision scale, with the aim of excluding salivary foam. These pairs of cotton rolls remained in place for 2 minutes during which time the patient could not swallow. After collection, the 2 rolls were removed, the assembly was reweighed, and the values were recorded.27,28,31 The following formula for the calculation of salivary flow measurement weight (CSFMW) has been recommended by Navazesh and Kumar31:
CSFMW ¼
DATA ANALYSES
Numerical variables were summarized using mean and standard deviation (SD) and categorical variables were summarized using absolute and relative frequencies. In bivariate analyses, the association of the overall scores of the UWQOL and the OFS with the sociodemographic variables, clinical characteristics, domains of PSS-HN, and salivary flow were verified with the Mann-Whitney U test (2 categories) or the KruskalWallis test (>2 categories). In multivariate analyses, multiple linear regression models were used to determine statistical predictors of overall scores of the UWQOL and the OFS. Because of the many analyses performed, statistical significance was set at a P value less than or equal to .01. Analyses were performed using the free statistical software package R 3.1.0 (R Core Team, Vienna, Austria; http://www.Rproject.org).
Results Sociodemographic and clinical variables are presented in Table 1. Seventy-three patients were included in the study, with no missing values for the questionnaires. The elapsed time from surgery to study participation ranged from 6 months to 32 years. There was similar participation by men (n = 37; 50.7%) and women (n = 36; 49.3%). The patients’ mean age was 62.2 years (SD, 13.3 yr). The most frequent histologic diagnoses of the maxillary resections were squamous cell carcinoma or epidermoid carcinoma (53.4%; n = 39). Regarding type of treatment, 35.6% (n = 26) underwent surgery, 45.2% (n = 33) underwent surgery and
posterior anterior measurement of weight ¼ g=min collection period
The rate of total stimulated salivary flow was considered hyposalivation when values were lower than 0.5 mL/min.31 Other Variables Sociodemographic data (age and gender) and clinical characteristics (tumor stage, treatment, classification of the maxillary defect,12 presence of a maxillary tooth, and type of rehabilitation prosthesis) were collected from the patients’ clinical records at the FOSP.
radiotherapy, and 19.2% (n = 14) underwent surgery, radiotherapy, and chemotherapy. Regarding TNM staging, 31.2% of patients had stage T2, 37.7% had stage T4, 73.8% had stage N0, and 96.8% had stage M0. According to the classification of maxillectomy defect,30 61.6% of patients had defects classified as Class 2b or lower. Regarding rehabilitation, 52 patients (71%) had an upper denture obturator and 21 (29%) had an upper partial obturator.
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4
SPEECH USING OBTURATOR PROSTHESIS
Table 1. SOCIODEMOGRAPHIC VARIABLES AND CLINICAL CHARACTERISTICS
Variable Sociodemographics Gender Age (yr), mean SD Clinical characteristics Treatment
Tumor stage
Nodal stage
Metastatic stage Classification of maxillary defect
Type of rehabilitation
Categories
Female Male
Surgery Surgery + radiotherapy Surgery + radiotherapy + chemotherapy T0 T1 T2 T3 T4 Carcinoma in situ N0 N1 N2 M0 M1 1
2a 2b 3a 3b 3c 4a 4b 4c Upper denture obturator Upper partial obturator
n (%)
36 (49.3) 37 (50.7) 62.2 13.2
26 (35.6) 33 (45.2) 14 (19.2)
2 (3.3) 3 (5.0) 19 (31.2) 13 (21.3) 23 (37.7) 1 (1.6) 45 (73.8) 7 (11.5) 9 (14.8) 60 (96.8) 2 (3.2) 12 (16.4)
26 (35.6) 7 (9.6) 5 (6.8) 10 (13.7) 1 (1.4) 6 (8.2) 2 (8.1) 1 (1.4) 52 (71.2) 21 (28.7)
Abbreviation: SD, standard deviation. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Table 2. BIVARIATE ASSOCIATIONS FOR SOCIODEMOGRAPHIC VARIABLES, CLINICAL CHARACTERISTICS, PSS-HN DOMAINS, AND SALIVARY FLOW RATE WITH OVERALL SCORE ON THE UNIVERSITY OF WASHINGTON QUALITY OF LIFE SCALE
Variable Sociodemographics Gender Female Male Age (yr) <60 $60 Clinical Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2bb >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator PSS-HN domains Eating in public Some restriction No restriction Understandability of speech Some restriction No restriction Normalcy of diet Some restriction No restriction Salivary flow Hyposalivation Normal salivary flow
n
Mean (SD)
P Value
36 37
78.2 (14.2) 74.8 (16.3)
.4205
29 44
79.7 (11.9) 74.4 (16.9)
.2277
26 47
81.5 (14.2) 73.7 (15.3)
.0229
24 36
77.0 (14.7) 76.1 (17.0)
.9519
48 25
79.2 (14.9) 71.3 (14.8)
.0268
42 31
75.5 (14.5) 77.9 (16.4)
.3178
20 53
82.0 (13.9) 74.4 (15.4)
.0451
40 33
71.7 (13.7) 82.3 (15.2)
.0010
41 32
69.8 (14.2) 85.0 (12.1)
<.0001
32 41
70.7 (14.9) 81.0 (14.2)
.0056
61 12
74.7 (15.4) 85.7 (10.8)
.0159
Q7
Abbreviations: PSS-HN, Performance Status Scale for Head and Neck Cancer Patients; RT, radiation therapy; SD, standard deviation. QOL AND OFS RESULTS AND BIVARIATE ANALYSES
The overall mean scores for the QoL and OFS after rehabilitation with the obturator were 76.5 (SD, 5.3) and 69.3 (SD, 12.6), respectively. Tables 2 and 3 present the associations of sociodemographic variables, clinical characteristics, domains of PSS-HN, and salivary flow with overall scores of the QoL and OFS, respectively. Patients who received postoperative radiation had a worse overall QoL score (P = .02) compared
Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
with those who did not receive this kind of treatment. Patients with defects classified as Class 2b or lower had better overall obturator performance (P < .001) and had better overall QoL score (P = .03) compared with those whose defects were classified as higher than 2b.
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SEIGNEMARTIN ET AL
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Q8
IMPACT OF PSS-HN SCORE ON OVERALL QOL AND OVERALL OBTURATOR FUNCTIONING
Table 3. BIVARIATE ASSOCIATIONS FOR SOCIODEMOGRAPHIC VARIABLES, CLINICAL CHARACTERISTICS, PSS-HN DOMAINS, AND SALIVARY FLOW RATE WITH OVERALL SCORE OF THE OBTURATOR FUNCTIONING SCALE
Sociodemographics Gender Female Male Age (yr) <60 $60 Clinical Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator PSS-HN domains Eating in public Some restriction No restriction Understandability of speech Some restriction No restriction Normalcy of diet Some restriction No restriction Salivary flow Hyposalivation Normal salivary flow
n
Mean (SD)
P Value
36 37
70.0 (11.3) 68.6 (12.0)
.6465
29 44
71.3 (10.6) 67.9 (12.1)
.2248
26 47
72.2 (11.3) 67.7 (11.6)
.2044
24 36
71.3 (12.7) 68.8 (12.1)
.3974
48 25
73.6 (9.7) 60.9 (10.2)
<.0001
42 31
69. (12.3) 69.7 (10.7)
.8712
20 53
71.3 (13.9) 68.5 (10.6)
.3402
40 33
64.8 (10.6) 74.7 (10.5)
.0006
41 32
62.8 (9.6) 77.5 (8.3)
<.0001
32 41
65.3 (10.9) 72.4 (11.3)
.0063
61 12
68.1 (11.5) 75.4 (10.6)
.0517
Abbreviations: PSS-HN, Performance Status Scale for Head and Neck Cancer Patients; RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Patients who had been rehabilitated with partial removable prostheses had a better overall QoL score compared with those with total removable prostheses (P = .045). There were no statistical associations of age, gender, tooth in the maxilla, and tumor stage with overall QoL and OFS scores.
Some patients (5%) reported that they always ate alone, 87% reported that their speech was usually or always understandable, and 56% reported no dietary restrictions. In statistical analyses, the 3 areas rated were grouped as no restrictions (score, 100) versus some restrictions (score, <100). Patients who reported restrictions in eating in public had worse overall scores for QoL (P < .01) and worse overall obturator performance (P < .01) compared with those with no restriction to eating in public (Tables 2, 3). Patients who reported restrictions in understandability of speech had worse overall QoL scores (P < .01). These patients also had worse overall obturator performance (P < .01) compared with those with no restriction in understandability of speech (Tables 2, 3). Patients who reported restrictions in normalcy of diet had worse overall QoL scores (P = .01) and worse overall obturator performance (P = .01) compared with those with no dietary restriction (Tables 2, 3). INFLUENCE OF SALIVARY FLOW ON OVERALL QOL AND OVERALL OFS SCORES
Sixty-one patients (65%) reported some degree of hyposalivation and 43 (70%) of them received radiotherapy or radiotherapy associated with chemotherapy. Patients who had had some degree of hyposalivation had worse overall QoL scores (P = .02). There was no statistical association between salivary flow and overall OFS scores (Tables 2, 3). ASSOCIATION OF PSS-HN DOMAINS AND SALIVARY FLOW WITH OTHER VARIABLES
There were no statistical associations between the PSS-HN domains and other variables (Table 4). Patients who received postoperative radiation therapy (P = .01) and rehabilitation with a total upper obturator more often had hyposalivation (P = .008; Table 5). MULTIVARIATE ANALYSES
Variables with a P value less than .20 were included in multiple linear regression analysis to determine the predictors of QoL and OFS scores in patients with maxillectomy and rehabilitation with obturator prostheses. Tables 6 and 7 present the results of multivariate analyses using B coefficient, its standard error, and P value. Understandability of speech was the only predictor affecting overall QoL scores (Table 6). Classification of the defect, eating in public, and understandability of speech were predictors of worse overall obturator functioning (Table 7).
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Table 4. ASSOCIATION BETWEEN PERFORMANCE STATUS SCALE FOR HEAD AND NECK CANCER PATIENTS DOMAINS AND OTHER VARIABLES
Eating in Public No Restrictions
Some Restrictions
Total
P Value
No Restrictions
Some Restrictions
Total
19 (58) 14 (42)
17 (42) 23 (57)
36 37
.2
19 (59) 13 (41)
17 (41) 24 (59)
12 (36) 21 (64)
17 (42) 23 (57)
29 44
.59
13 (41) 19 (59)
12 (36) 21 (64)
14 (35) 26 (65)
26 47
.9
9 (33) 18 (67)
15 (45) 18 (55)
24 36
25 (76) 8 (24)
23 (57) 17 (42)
16 (48) 17 (52) 10 (30) 23 (70)
Normalcy of Diet P Value
No Restrictions
Some Restrictions
Total
36 37
.129
20 (49) 21 (51)
16 (50) 16 (50)
36 37
.92
16 (39) 25 (61)
29 44
.89
15 (37) 26 (63)
14 (44) 18 (56)
29 44
.53
14 (44) 18 (56)
12 (29) 29 (71)
26 47
.2
16 (39) 25 (61)
10 (31) 22 (69)
26 47
.49
.34
12 (43) 16 (57)
12 (38) 20 (62)
24 36
.673
12 (35) 22 (65)
12 (46) 14 (54)
24 36
.39
48 25
.1
24 (75) 8 (25)
24 (59) 17 (41)
48 25
.141
29 (71) 12 (29)
19 (59) 13 (41)
48 25
.31
26 (65) 14 (35)
42 31
.16
17 (53) 15 (47)
25 (61) 16 (39)
42 31
.501
20 (49) 21 (51)
22 (69) 10 (31)
42 31
.09
10 (25) 30 (75)
20 53
.61
12 (38) 20 (62)
8 (20) 33 (80)
20 53
.087
13 (32) 28 (68)
7 (22) 25 (78)
20 53
.35
P Value
Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
SPEECH USING OBTURATOR PROSTHESIS
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Gender Female Male Age (yr) <60 $60 Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator
Understandability of Speech
617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672
7
SEIGNEMARTIN ET AL
673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728
Table 5. ASSOCIATION BETWEEN SALIVARY FLOW AND OTHER VARIABLES
Salivary Flow
Gender Female Male Age (yr) <60 $60 Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator
Normal
Hyposalivation
Total
P Value
7 (58) 5 (42)
29 (48) 32 (52)
36 37
.4942
7 (58) 5 (42)
22 (36) 39 (64)
29 44
.1496
8 (67) 4 (33)
18 (30) 43 (70)
26 47
.014
6 (55) 5 (45)
18 (37) 31 (63)
24 36
.2759
9 (75) 3 (25)
39 (64) 22 (36)
48 25
.4603
5 (42) 7 (58)
37 (61) 24 (39)
42 31
.2238
7 (58) 5 (42)
13 (21) 48 (79)
20 53
.0086
Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Discussion In the present univariate and multivariate analyses, the best predictor of overall QoL and OFS sores in patients rehabilitated with obturators was the understandability of speech domain of the PSS-HN questionnaire. It was the only predictor associated with overall QoL score and with the classification of maxillary defect and eating in public domains of the PSS-HN was a predictor of overall OFS score at multivariate analyses. Patients with some restriction of understand-
ability of speech showed worse overall scores in for QoL and the OFS. A review of the literature review showed that no published studies have assessed functional performance in relation to overall QoL and OFS scores in this group of patients. The only study that discussed an association for overall QoL and OFS scores with sociodemographic variables and clinical characteristics was by Chigurupati et al.16 Similar to the present study, their univariate analyses associated
Table 6. MULTIPLE LINEAR REGRESSION OF STATISTICALLY IMPORTANT VARIABLES FROM BIVARIATE ANALYSES OF THE UNIVERSITY OF WASHINGTON QUALITY OF LIFE SCALE
Variable
B Coefficient
Standard Error
P Value
3.43 3.25 2.42 5.62 11.32 4.17 3.67
3.36 3.30 3.58 3.45 3.16 3.48 4.44
.3111 .3279 .5018 .1079 .0006 .2352 .4118
Postoperative RT (no vs yes) Classification of maxillary defect (#2b vs >2b) Type of obturator (partial upper obturator vs total upper obturator) Eating in public (no restrictions vs some restrictions) Understandability of speech (no restrictions vs some restrictions) Normalcy of diet (no restrictions vs some restrictions) Salivary flow (hyposalivation vs some restriction) Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
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729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784
785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840
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SPEECH USING OBTURATOR PROSTHESIS
Table 7. MULTIPLE LINEAR REGRESSION OF STATISTICALLY IMPORTANT VARIABLES FROM BIVARIATE ANALYSES OF THE OBTURATOR FUNCTIONING SCALE
Variable
B Coefficient
Standard Error
P Value
9.42 5.14 11.83 1.56
1.81 1.93 1.74 1.91
<.0001 .0098 <.0001 .4173
Classification of maxillary defect (#2b vs >2b) Eating in public (no restrictions vs some restrictions) Understandability of speech (no restrictions vs some restrictions) Normalcy of diet (no restrictions vs some restrictions) Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
postoperative radiation therapy with worse overall QoL scores. In contrast to the study by Chigurupati et al,16 the present univariate analyses associated classification of the maxillary defect with overall OFS scores in patients rehabilitated with obturators. The limitations of this cross-sectional study are similar to those of others,5,8,10,11,16,21 which are related to the design of the study that does not allow evaluation of temporal changes in QoL and OFS scores14,16,22 and there is neither a baseline QoL nor OFS score before treatment. However, at the time of these analyses, it did not to affect the results. The need for increasing numbers of professionals trained in dental oncology is clear. Thus, there is a growing need for a multidisciplinary oncology team formed by head and neck surgeons, oncologists, general practitioners, dentists, specialists in oncology and maxillofacial prosthodontics, speech therapists, psychologists, and nurses to educate patients, ensure good restoration, and create protocols that in the future might provide more predictable functional and esthetic results.32,33 Although the present study found a good QoL for these patients, a more detailed follow-up might show small details that could be applied directly to the care of these patients and thus improve their QoL. Similarly, problems with chewing and eating restraints can interfere with the socialization of these patients with others in situations where food and drink are important aspects of the activity.25 In conclusion, the present results showed that patients with maxillectomy and rehabilitation with an obturator prosthesis had good overall QoL and OFS scores. The effects of functional performance of eating in public, understandability of speech, and normalcy of diet on QoL and OFS scores have not been previously reported in the literature, and more studies are needed to confirm these findings. Longitudinal studies using the same scales as in the present study through the various phases of illness, treatment, and rehabilitation might clarify the present findings.
2.
3.
4. 5. 6.
7.
8. 9.
10.
11. 12. 13. 14.
15.
16.
17.
18. 19.
20.
21.
References 1. Yanamoto S, Yamada S, Takahashi H, et al: Benefits of maxillectomy with internal dissection of the masticator space by trans-
22.
mandibular approach in the surgical management of malignant tumours of the upper gingiva and hard palate: A clinical review of 10 cases. Int J Oral Maxillofac Surg 1:7, 2014 Nagy J, Braunitzer G, Antal M, et al: QOL in head and neck cancer patients after tumor therapy and subsequent rehabilitation: An exploratory study. Qual Life Res 23:135, 2014 Sobin LH, Gospodarowicz MK, Wittekind CH: TNM Classification of Malignant Tumor. Traduzido por Eisenberg ALA (ed 7). Rio de Janeiro, Brazil, INCA, 2012. Y€ ucel A, Cinar C, Aydin Y, et al: Malignant tumors requiring maxillectomy. J Craniofac Surg 11:418, 2000 Irish J, Sandhu N, Sipson C, et al: QOL in patients with maxillectomy. Head Neck 31:813, 2009 de Carvalho-Teles V, Pegoraro-Krook MI, Lauris JR: Speech evaluation with and without palatal obturator in patients submitted to maxillectomy. J Appl Oral Sci 14:421, 2006 Patton DW, Ali A, Davies R, et al: Oral rehabilitation and QOL following the treatment of oral cancer. Dent Update 21:231, 1994 Riaz N, Warriach RA: QOL in patients with obturator prostheses. J Ayub Med Coll Abbottabad 22:121, 2010 Rieger JM, Wolfaardt JF, Jha N, et al: Maxillary obturators: The relationship between patient satisfaction and speech outcome. Head Neck 25:859, 2003 Depprich R, Naujoks C, Lind D, et al: Evaluation of the QOL of patients with maxillofacial defects after prosthodontic therapy with obturator prostheses. Int J Oral Maxillofac Surg 40:71, 2011 Korniblith AB, Zlotolow IM, Gooen J, et al: QOL of maxillectomy patients using an obturator prosthesis. Head Neck 18:323, 1996 Brown JS, Rogers SN, McNally DN, et al: A modified classification for the maxillectomy defect. Head Neck 22:17, 2000 Borlage G: Use of obturators in rehabilitation of maxillectomy defects. Ann R Australas Coll Dent Surg 15:75, 2000 Rogers SN, Lowe D, Brown SJ, et al: Health-related QOL after maxillectomy: A comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 61:174, 2003 Ali A, Fardy J, Patton W: Maxillectomy, to reconstruct or obdurate? Results of a survey of oral and maxillofacial surgeons. Br J Oral Maxillofac Surg 33:207, 1995 Chigurupati R, Aloor N, Salas R, et al: QOL after maxillectomy and prosthetic obturator rehabilitation. J Oral Maxillofac Surg 71:1471, 2013 Rogers SN, Gwanne S, Lowe D, et al: The addition of mood and anxiety domains to the University of Washington QOL scale. Head Neck 24:521, 2002 Chandu A, Smith AC, Rogers SN: Health-related QOL in oral cancer: A review. J Oral Maxillofac Surg 64:495, 2006 Rogers SN, Ahad SA, Murphy AP: A structured review and theme analysis of papers published on ‘QOL’ in head and neck cancer: 2000-2005. Oral Oncol 43:843, 2007 Sayed SJ, Elmiyeh B, Evans PR, et al: QOL and outcomes research in head and neck cancer: A review of the state of the discipline and likely future directions. Cancer Treat Rev 35:397, 2009 Hertrampf K, Wenz HJ, Lehmann KM, et al: QOL of patients with maxillofacial defects after treatment for malignancy. Int J Prosthodont 17:657, 2004 Rogers SN, Fisher SE, Woolgar JA: A review of QOL assessment in oral cancer. Int J Oral Maxillofac Surg 28:99, 1999
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841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896
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897 898 899 900 901 902 903 904 905 906 907 908
Q5
23. Kumar P, Alvi AH, Rao J, et al: Assessment of the QOL in maxillectomy patients: A longitudinal study. J Adv Prosthodont 5:29, 2013 24. Vartanian JG, Carvalho AL, Yueh B, et al: Brazilian-Portuguese validation of the University of Washington QOL Questionnaire for patients with head and neck cancer. Head Neck 28:1115, 2006 25. List MA, Sterr RC, Lansky SB: A performance status scale for head and neck cancer patients. Cancer 66:564, 1990 26. Hassan SJ, Weymuller EA Jr: Assessment of QOL in head and neck cancer patients. Head Neck 15:485, 1993 27. Pupo D, Bussoloti FI, Liquidato BM, et al: A proposal for a practical method of sialometry. Rev Bras Otorinolaringol 68: 219, 2002 28. Camargo KAN, Pupo D, Bussoloti FI: Sialometria. Acta Orl 23: 129, 2005
29. Conceic¸~ao MD, Marocchio MS, Fagundes RL: Sialometric technique for use in clinical practice. Rev Assoc Paul Cir Dent 60: 300, 2006 (in Portuguese). 30. Sood AJ, Fox NF, O’Connell BP, et al: Salivary gland transfer to prevent radiation-induced xerostomia: A systematic review and meta-analysis. Oral Oncol 50:77, 2014 31. Navazesh M, Kumar SKS: Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 139(suppl 2):35S, 2008 32. Sullivan M: The expanding role of dental oncology in head and neck surgery. Surg Oncol Clin North Am 13:37, 2004 33. Eades M, Murphy J, Carney S, et al: Effect of an interdisciplinary rehabilitation program on QOL in patients with head and neck cancer: Review of clinical experience. Head Neck 35:343, 2013
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909 910 911 912 913 914 915 916 917 918 919 920
CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Understandability of Speech Predicts Quality of Life Among Maxillectomy Patients Restored With Obturator Prosthesis Q9
Crystianne Pacheco Seignemartin, DDS,* Milton E. Miranda, DDS, MS, PhD,y Jo~ ao Gualberto C. Luz, DDS, MS, PhD,z and Rubens G. Teixeira, DDS, MS, PhDx Purpose:
Maxillary malignant tumor resection by maxillectomy might lead to defects that can be repaired by prosthetic obturation. The aim of this study was to associate quality of life (QoL) and the Obturator Functioning Scale (OFS) with functional performance and salivary flow rate in Brazilian patients rehabilitated with an obturator prosthesis.
Patients and Methods:
This retrospective cross-sectional study included patients who underwent surgical resection with or without radiotherapy without or without chemotherapy and the rehabilitation with an obturator prosthesis at the Fundac¸~ao Oncocentro de S~ao Paulo (S~ao Paulo, Brazil). The predictor variables were Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) domains and clinical evaluation of salivary flow rate. The outcome variables were overall scores obtained by the University of Washington QoL Scale (UWQOL) and the OFS. Sociodemographics (gender and age) and clinical characteristics (postoperative radiotherapy, tumor stage, classification of maxillary defect, tooth in maxilla, and type of obturator) also were evaluated. Univariate and multivariate analyses were performed to determinate whether PSS-HN domains and salivary flow were predictors of overall QoL and overall OFS.
Results:
The sample was composed of 73 patients with a mean age of 62 years and 51% were men. According to the PSS-HN domains, some patients (5%) always ate alone, 87% reported that speech is usually or always understandable, and 56% had no dietary restrictions. Sixty-one patients (65%) reported some degree of hyposalivation. The mean overall QoL score was 76.5 (standard deviation, 5.3). Patients with compromised PSS-HN domains had significantly worse overall UWQOL scores (P = .001, P < .001, and P = .006, respectively). In multiple regression analyses, understandability of speech was the only predictor of overall QoL scores.
Conclusion: Q3
Q2
The results of this study showed that understandability of speech was the only predictor of overall QoL scores. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2015 Oral cancer represents about 1 to 3% of all human cancers and is the sixth most frequent cancer worldwide. Ten percent of all oral cancers that occur in the oral cavity subsites of the upper gingiva and hard palate have similar clinical presentations and management because of their adjacent anatomies.1,2
Malignant tumors3 requiring maxillofacial surgeries4 can lead to defects caused by maxillectomy that result in serious esthetic and functional disabilities2-12 involving swallowing and speech.2,4-12 Maxillectomy defects can be repaired by prosthetic obturation or even reconstruction using free or microsurgical transplants, grafts, and distant or regional flaps.2,4,6,12-15
*Professor, Department of Maxillofacial Prosthodontics, Fundac¸~ao Oncocentro de S~ao Paulo, S~ao Paulo, Brazil.
S~ao Paulo, Rua Oscar Freire, 2396, 1 andar, S~ao Paulo, SP 05409-012,
Brazil; e-mail: [email protected]
yProfessor, Graduated Prosthodontic Department, School of
Received August 10 2014
Dentistry, S~ao Leoplodo Mandic, Campinas, Brazil. zFull Professor, Department of Oral and Maxillofacial Surgery,
Ó 2015 American Association of Oral and Maxillofacial Surgeons
School of Dentistry, University of S~ao Paulo, S~ao Paulo, Brazil.
0278-2391/15/00491-7
Accepted April 21 2015
xProfessor, Department of Surgery and Traumatology, School of
http://dx.doi.org/10.1016/j.joms.2015.04.031
Dentistry, S~ao Leopoldo Mandic, Campinas, Brazil. Address correspondence and reprint requests to Dr Seignemartin: Department of Maxillofacial Rehabilitation, Fundac¸~ao Oncocentro de
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2
SPEECH USING OBTURATOR PROSTHESIS
The extension of skin loss,4 the size of the defect,2,4,15 and the feasibility of having a team with a surgeon and a prosthodontist influence the method of reconstruction.4,13,15,16 However, an obturator prosthesis is still considered one of the most efficient rehabilitation tools in larger maxillary resections because it is fast, is low cost, has the possibility of modification according to the patients’ needs,6 an enhancement of intraoral functional, and the decrease of eventual cosmetic deformity by supplying missing teeth and supporting the lip and cheek.2 Recently, the recognition of the multidimensional effect of maxillofacial tumors on a patient’s quality of life (QoL) has led to increased interest.2,5,8-10,17-21 It has been proposed that QoL parameters should be assessed in addition to conventional clinical criteria21 to provide the clinician a choice from a variety of validated questionnaires22 and include them in the daily routine outcome parameter.17 Studies in the literature on QoL in patients with maxillectomy and rehabilitation with obturators5,7,8,10,11,14,16,21,23 have shown that the correlation between obturator function (Obturator Functioning Scale [OFS]) and QoL5,8,10,11,16,23 can be influenced by clinical factors, such as type of tumor and stage of disease, extent of the ablative defect, postoperative radiation therapy, number and condition of remaining maxillary teeth, and demographic and other social variables.5,8,14,16,23 To the best of the authors’ knowledge, studies of this kind of the Brazilian population are rare.6 After maxillectomy, patients can develop problems related to functional performance of eating and talking5,8,11,16 and xerostomia related to radiotherapy.2,10,24 There is a gap in the current literature associating this functional status (Performance Status Scale for Head and Neck Cancer Patients [PSS-HN])25 with QoL and obturator function. The purpose of this study was to evaluate whether functional performance of eating in public, understandability of speech, normalcy of diet, and salivary flow rate in patients with maxillectomy and rehabilitation with obturators are predictors of overall QoL and obturator function. The authors hypothesized that low functional performance25 and a low salivary flow rate4,7,14,16,23 would negatively influence the QoL and obturator function of these patients. The specific aims of the study were to associate clinical features and demographic variables with overall QoL and overall obturator functioning.
Patients and Methods STUDY DESIGN AND SAMPLE
This retrospective cross-sectional study was conducted at the Fundac¸~ao Oncocentro de Sao Paulo
(FOSP; S~ao Paulo, Brazil). From December 14, 2012 through February 14, 2013, the authors invited all patients who were treated at the maxillofacial rehabilitation department and were undergoing revision of their obturator prosthesis to participate in the study. Included were patients older than 18 years; men and women regardless of ethnicity; those treated for oral squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, or other tumors; and who underwent surgical resection with or without radiotherapy with or without chemotherapy and then rehabilitation with obturators. Patients were excluded as study subjects if they had tumor recurrence. This study was conducted after approval by the research ethics committee in humans in S~ao Leopoldo Mandic School of Dentistry (Campinas, Brazil) under protocol number 2012/0010 and by the FOSP supported by the Brazilian Department of Health to assist health policy on cancer in the state. VARIABLES
A QoL questionnaire for patients with head and neck cancer, The University of Washington QoL Scale (UWQOL; version 4); 2 performance measurements, the OFS and the PSS-HN; and clinical evaluation of salivary flow rate were used in this study. The questionnaires were given to the patients after signing an informed consent form. A single maxillofacial prosthodontist interviewer administrated all validated questionnaires and collected data on salivary flow. Outcome Variables Primary outcome—overall UWQOL score. This questionnaire is a self-administered scale consisting of 15 questions26 that is culturally appropriate and psychometrically valid in Brazilian Portuguese.24 The first 12 domains concern areas of daily living often affected by treatment of head and neck cancer, such as pain, disfigurement, activity, recreation and entertainment, chewing, swallowing, speech, shoulder disability, taste, saliva, and 2 new emotional domains of mood and anxiety. Outcome was determined by the accepted standard of an overall composite score.16 To describe current functional status, each domain has a maximum score of 100 points, indicating the highest level of function, and a minimum score of 0, indicating the poorest level of function. Secondary outcome—OFS score. This scale consists of 15 questions to measure patients’ ability to eat and speak with an obturator prosthesis and their satisfaction with the restoration of lip position and its cosmetic effects. Dryness of mouth, an effect of radiotherapy on major and possibly minor salivary glands, was included as an item in the scale because poor lubrication of the mouth is a possible contributor to
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poorer fit or functioning of the prosthesis.11 Another item, ‘‘difficulty talking on the phone,’’ was added to the scale to assess communication difficulties in the absence of visual cues.5 The answer to each question is rated in a numerical value from 0 to 100. A score of 0 indicates maximum suffering or dissatisfaction and a score of 100 indicates that the patient was asymptomatic or extremely satisfied in the respective domain.16 Predictor Variables Primary predictor—PSS-HN score. This questionnaire was designed to evaluate the performance of functions most likely to be affected by head and neck cancer and eating in public. It is a clinicianrated instrument consisting of 3 scales: normalcy of diet, understandability of speech, and eating in public. The 3 areas of function are rated from 100 to 0, with a score of 100 representing no dysfunction.25 Secondary predictor—Measurement of salivary flow. To objectively establish a patient’s perception of saliva flow that featured xerostomia, the volumetric method was chosen,27-30 in which quantitative gravimetric sialometry using a taste stimulus (2 drops of 2% citric acid) measured the absorption of saliva by cotton rolls, which were weighed on a precision scale, with the aim of excluding salivary foam. These pairs of cotton rolls remained in place for 2 minutes during which time the patient could not swallow. After collection, the 2 rolls were removed, the assembly was reweighed, and the values were recorded.27,28,31 The following formula for the calculation of salivary flow measurement weight (CSFMW) has been recommended by Navazesh and Kumar31:
CSFMW ¼
DATA ANALYSES
Numerical variables were summarized using mean and standard deviation (SD) and categorical variables were summarized using absolute and relative frequencies. In bivariate analyses, the association of the overall scores of the UWQOL and the OFS with the sociodemographic variables, clinical characteristics, domains of PSS-HN, and salivary flow were verified with the Mann-Whitney U test (2 categories) or the KruskalWallis test (>2 categories). In multivariate analyses, multiple linear regression models were used to determine statistical predictors of overall scores of the UWQOL and the OFS. Because of the many analyses performed, statistical significance was set at a P value less than or equal to .01. Analyses were performed using the free statistical software package R 3.1.0 (R Core Team, Vienna, Austria; http://www.Rproject.org).
Results Sociodemographic and clinical variables are presented in Table 1. Seventy-three patients were included in the study, with no missing values for the questionnaires. The elapsed time from surgery to study participation ranged from 6 months to 32 years. There was similar participation by men (n = 37; 50.7%) and women (n = 36; 49.3%). The patients’ mean age was 62.2 years (SD, 13.3 yr). The most frequent histologic diagnoses of the maxillary resections were squamous cell carcinoma or epidermoid carcinoma (53.4%; n = 39). Regarding type of treatment, 35.6% (n = 26) underwent surgery, 45.2% (n = 33) underwent surgery and
posterior anterior measurement of weight ¼ g=min collection period
The rate of total stimulated salivary flow was considered hyposalivation when values were lower than 0.5 mL/min.31 Other Variables Sociodemographic data (age and gender) and clinical characteristics (tumor stage, treatment, classification of the maxillary defect,12 presence of a maxillary tooth, and type of rehabilitation prosthesis) were collected from the patients’ clinical records at the FOSP.
radiotherapy, and 19.2% (n = 14) underwent surgery, radiotherapy, and chemotherapy. Regarding TNM staging, 31.2% of patients had stage T2, 37.7% had stage T4, 73.8% had stage N0, and 96.8% had stage M0. According to the classification of maxillectomy defect,30 61.6% of patients had defects classified as Class 2b or lower. Regarding rehabilitation, 52 patients (71%) had an upper denture obturator and 21 (29%) had an upper partial obturator.
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337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
4
SPEECH USING OBTURATOR PROSTHESIS
Table 1. SOCIODEMOGRAPHIC VARIABLES AND CLINICAL CHARACTERISTICS
Variable Sociodemographics Gender Age (yr), mean SD Clinical characteristics Treatment
Tumor stage
Nodal stage
Metastatic stage Classification of maxillary defect
Type of rehabilitation
Categories
Female Male
Surgery Surgery + radiotherapy Surgery + radiotherapy + chemotherapy T0 T1 T2 T3 T4 Carcinoma in situ N0 N1 N2 M0 M1 1
2a 2b 3a 3b 3c 4a 4b 4c Upper denture obturator Upper partial obturator
n (%)
36 (49.3) 37 (50.7) 62.2 13.2
26 (35.6) 33 (45.2) 14 (19.2)
2 (3.3) 3 (5.0) 19 (31.2) 13 (21.3) 23 (37.7) 1 (1.6) 45 (73.8) 7 (11.5) 9 (14.8) 60 (96.8) 2 (3.2) 12 (16.4)
26 (35.6) 7 (9.6) 5 (6.8) 10 (13.7) 1 (1.4) 6 (8.2) 2 (8.1) 1 (1.4) 52 (71.2) 21 (28.7)
Abbreviation: SD, standard deviation. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Table 2. BIVARIATE ASSOCIATIONS FOR SOCIODEMOGRAPHIC VARIABLES, CLINICAL CHARACTERISTICS, PSS-HN DOMAINS, AND SALIVARY FLOW RATE WITH OVERALL SCORE ON THE UNIVERSITY OF WASHINGTON QUALITY OF LIFE SCALE
Variable Sociodemographics Gender Female Male Age (yr) <60 $60 Clinical Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2bb >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator PSS-HN domains Eating in public Some restriction No restriction Understandability of speech Some restriction No restriction Normalcy of diet Some restriction No restriction Salivary flow Hyposalivation Normal salivary flow
n
Mean (SD)
P Value
36 37
78.2 (14.2) 74.8 (16.3)
.4205
29 44
79.7 (11.9) 74.4 (16.9)
.2277
26 47
81.5 (14.2) 73.7 (15.3)
.0229
24 36
77.0 (14.7) 76.1 (17.0)
.9519
48 25
79.2 (14.9) 71.3 (14.8)
.0268
42 31
75.5 (14.5) 77.9 (16.4)
.3178
20 53
82.0 (13.9) 74.4 (15.4)
.0451
40 33
71.7 (13.7) 82.3 (15.2)
.0010
41 32
69.8 (14.2) 85.0 (12.1)
<.0001
32 41
70.7 (14.9) 81.0 (14.2)
.0056
61 12
74.7 (15.4) 85.7 (10.8)
.0159
Q7
Abbreviations: PSS-HN, Performance Status Scale for Head and Neck Cancer Patients; RT, radiation therapy; SD, standard deviation. QOL AND OFS RESULTS AND BIVARIATE ANALYSES
The overall mean scores for the QoL and OFS after rehabilitation with the obturator were 76.5 (SD, 5.3) and 69.3 (SD, 12.6), respectively. Tables 2 and 3 present the associations of sociodemographic variables, clinical characteristics, domains of PSS-HN, and salivary flow with overall scores of the QoL and OFS, respectively. Patients who received postoperative radiation had a worse overall QoL score (P = .02) compared
Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
with those who did not receive this kind of treatment. Patients with defects classified as Class 2b or lower had better overall obturator performance (P < .001) and had better overall QoL score (P = .03) compared with those whose defects were classified as higher than 2b.
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Q8
IMPACT OF PSS-HN SCORE ON OVERALL QOL AND OVERALL OBTURATOR FUNCTIONING
Table 3. BIVARIATE ASSOCIATIONS FOR SOCIODEMOGRAPHIC VARIABLES, CLINICAL CHARACTERISTICS, PSS-HN DOMAINS, AND SALIVARY FLOW RATE WITH OVERALL SCORE OF THE OBTURATOR FUNCTIONING SCALE
Sociodemographics Gender Female Male Age (yr) <60 $60 Clinical Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator PSS-HN domains Eating in public Some restriction No restriction Understandability of speech Some restriction No restriction Normalcy of diet Some restriction No restriction Salivary flow Hyposalivation Normal salivary flow
n
Mean (SD)
P Value
36 37
70.0 (11.3) 68.6 (12.0)
.6465
29 44
71.3 (10.6) 67.9 (12.1)
.2248
26 47
72.2 (11.3) 67.7 (11.6)
.2044
24 36
71.3 (12.7) 68.8 (12.1)
.3974
48 25
73.6 (9.7) 60.9 (10.2)
<.0001
42 31
69. (12.3) 69.7 (10.7)
.8712
20 53
71.3 (13.9) 68.5 (10.6)
.3402
40 33
64.8 (10.6) 74.7 (10.5)
.0006
41 32
62.8 (9.6) 77.5 (8.3)
<.0001
32 41
65.3 (10.9) 72.4 (11.3)
.0063
61 12
68.1 (11.5) 75.4 (10.6)
.0517
Abbreviations: PSS-HN, Performance Status Scale for Head and Neck Cancer Patients; RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Patients who had been rehabilitated with partial removable prostheses had a better overall QoL score compared with those with total removable prostheses (P = .045). There were no statistical associations of age, gender, tooth in the maxilla, and tumor stage with overall QoL and OFS scores.
Some patients (5%) reported that they always ate alone, 87% reported that their speech was usually or always understandable, and 56% reported no dietary restrictions. In statistical analyses, the 3 areas rated were grouped as no restrictions (score, 100) versus some restrictions (score, <100). Patients who reported restrictions in eating in public had worse overall scores for QoL (P < .01) and worse overall obturator performance (P < .01) compared with those with no restriction to eating in public (Tables 2, 3). Patients who reported restrictions in understandability of speech had worse overall QoL scores (P < .01). These patients also had worse overall obturator performance (P < .01) compared with those with no restriction in understandability of speech (Tables 2, 3). Patients who reported restrictions in normalcy of diet had worse overall QoL scores (P = .01) and worse overall obturator performance (P = .01) compared with those with no dietary restriction (Tables 2, 3). INFLUENCE OF SALIVARY FLOW ON OVERALL QOL AND OVERALL OFS SCORES
Sixty-one patients (65%) reported some degree of hyposalivation and 43 (70%) of them received radiotherapy or radiotherapy associated with chemotherapy. Patients who had had some degree of hyposalivation had worse overall QoL scores (P = .02). There was no statistical association between salivary flow and overall OFS scores (Tables 2, 3). ASSOCIATION OF PSS-HN DOMAINS AND SALIVARY FLOW WITH OTHER VARIABLES
There were no statistical associations between the PSS-HN domains and other variables (Table 4). Patients who received postoperative radiation therapy (P = .01) and rehabilitation with a total upper obturator more often had hyposalivation (P = .008; Table 5). MULTIVARIATE ANALYSES
Variables with a P value less than .20 were included in multiple linear regression analysis to determine the predictors of QoL and OFS scores in patients with maxillectomy and rehabilitation with obturator prostheses. Tables 6 and 7 present the results of multivariate analyses using B coefficient, its standard error, and P value. Understandability of speech was the only predictor affecting overall QoL scores (Table 6). Classification of the defect, eating in public, and understandability of speech were predictors of worse overall obturator functioning (Table 7).
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505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 6
Table 4. ASSOCIATION BETWEEN PERFORMANCE STATUS SCALE FOR HEAD AND NECK CANCER PATIENTS DOMAINS AND OTHER VARIABLES
Eating in Public No Restrictions
Some Restrictions
Total
P Value
No Restrictions
Some Restrictions
Total
19 (58) 14 (42)
17 (42) 23 (57)
36 37
.2
19 (59) 13 (41)
17 (41) 24 (59)
12 (36) 21 (64)
17 (42) 23 (57)
29 44
.59
13 (41) 19 (59)
12 (36) 21 (64)
14 (35) 26 (65)
26 47
.9
9 (33) 18 (67)
15 (45) 18 (55)
24 36
25 (76) 8 (24)
23 (57) 17 (42)
16 (48) 17 (52) 10 (30) 23 (70)
Normalcy of Diet P Value
No Restrictions
Some Restrictions
Total
36 37
.129
20 (49) 21 (51)
16 (50) 16 (50)
36 37
.92
16 (39) 25 (61)
29 44
.89
15 (37) 26 (63)
14 (44) 18 (56)
29 44
.53
14 (44) 18 (56)
12 (29) 29 (71)
26 47
.2
16 (39) 25 (61)
10 (31) 22 (69)
26 47
.49
.34
12 (43) 16 (57)
12 (38) 20 (62)
24 36
.673
12 (35) 22 (65)
12 (46) 14 (54)
24 36
.39
48 25
.1
24 (75) 8 (25)
24 (59) 17 (41)
48 25
.141
29 (71) 12 (29)
19 (59) 13 (41)
48 25
.31
26 (65) 14 (35)
42 31
.16
17 (53) 15 (47)
25 (61) 16 (39)
42 31
.501
20 (49) 21 (51)
22 (69) 10 (31)
42 31
.09
10 (25) 30 (75)
20 53
.61
12 (38) 20 (62)
8 (20) 33 (80)
20 53
.087
13 (32) 28 (68)
7 (22) 25 (78)
20 53
.35
P Value
Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
SPEECH USING OBTURATOR PROSTHESIS
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Gender Female Male Age (yr) <60 $60 Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator
Understandability of Speech
617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672
7
SEIGNEMARTIN ET AL
673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728
Table 5. ASSOCIATION BETWEEN SALIVARY FLOW AND OTHER VARIABLES
Salivary Flow
Gender Female Male Age (yr) <60 $60 Postoperative RT No Yes Tumor stage I + II III + IV Classification of maxillary defect #2b >2b Tooth in maxilla No Yes Type of obturator Partial upper obturator Total upper obturator
Normal
Hyposalivation
Total
P Value
7 (58) 5 (42)
29 (48) 32 (52)
36 37
.4942
7 (58) 5 (42)
22 (36) 39 (64)
29 44
.1496
8 (67) 4 (33)
18 (30) 43 (70)
26 47
.014
6 (55) 5 (45)
18 (37) 31 (63)
24 36
.2759
9 (75) 3 (25)
39 (64) 22 (36)
48 25
.4603
5 (42) 7 (58)
37 (61) 24 (39)
42 31
.2238
7 (58) 5 (42)
13 (21) 48 (79)
20 53
.0086
Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
Discussion In the present univariate and multivariate analyses, the best predictor of overall QoL and OFS sores in patients rehabilitated with obturators was the understandability of speech domain of the PSS-HN questionnaire. It was the only predictor associated with overall QoL score and with the classification of maxillary defect and eating in public domains of the PSS-HN was a predictor of overall OFS score at multivariate analyses. Patients with some restriction of understand-
ability of speech showed worse overall scores in for QoL and the OFS. A review of the literature review showed that no published studies have assessed functional performance in relation to overall QoL and OFS scores in this group of patients. The only study that discussed an association for overall QoL and OFS scores with sociodemographic variables and clinical characteristics was by Chigurupati et al.16 Similar to the present study, their univariate analyses associated
Table 6. MULTIPLE LINEAR REGRESSION OF STATISTICALLY IMPORTANT VARIABLES FROM BIVARIATE ANALYSES OF THE UNIVERSITY OF WASHINGTON QUALITY OF LIFE SCALE
Variable
B Coefficient
Standard Error
P Value
3.43 3.25 2.42 5.62 11.32 4.17 3.67
3.36 3.30 3.58 3.45 3.16 3.48 4.44
.3111 .3279 .5018 .1079 .0006 .2352 .4118
Postoperative RT (no vs yes) Classification of maxillary defect (#2b vs >2b) Type of obturator (partial upper obturator vs total upper obturator) Eating in public (no restrictions vs some restrictions) Understandability of speech (no restrictions vs some restrictions) Normalcy of diet (no restrictions vs some restrictions) Salivary flow (hyposalivation vs some restriction) Abbreviation: RT, radiation therapy. Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
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729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784
785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840
8
SPEECH USING OBTURATOR PROSTHESIS
Table 7. MULTIPLE LINEAR REGRESSION OF STATISTICALLY IMPORTANT VARIABLES FROM BIVARIATE ANALYSES OF THE OBTURATOR FUNCTIONING SCALE
Variable
B Coefficient
Standard Error
P Value
9.42 5.14 11.83 1.56
1.81 1.93 1.74 1.91
<.0001 .0098 <.0001 .4173
Classification of maxillary defect (#2b vs >2b) Eating in public (no restrictions vs some restrictions) Understandability of speech (no restrictions vs some restrictions) Normalcy of diet (no restrictions vs some restrictions) Seignemartin et al. Speech Using Obturator Prosthesis. J Oral Maxillofac Surg 2015.
postoperative radiation therapy with worse overall QoL scores. In contrast to the study by Chigurupati et al,16 the present univariate analyses associated classification of the maxillary defect with overall OFS scores in patients rehabilitated with obturators. The limitations of this cross-sectional study are similar to those of others,5,8,10,11,16,21 which are related to the design of the study that does not allow evaluation of temporal changes in QoL and OFS scores14,16,22 and there is neither a baseline QoL nor OFS score before treatment. However, at the time of these analyses, it did not to affect the results. The need for increasing numbers of professionals trained in dental oncology is clear. Thus, there is a growing need for a multidisciplinary oncology team formed by head and neck surgeons, oncologists, general practitioners, dentists, specialists in oncology and maxillofacial prosthodontics, speech therapists, psychologists, and nurses to educate patients, ensure good restoration, and create protocols that in the future might provide more predictable functional and esthetic results.32,33 Although the present study found a good QoL for these patients, a more detailed follow-up might show small details that could be applied directly to the care of these patients and thus improve their QoL. Similarly, problems with chewing and eating restraints can interfere with the socialization of these patients with others in situations where food and drink are important aspects of the activity.25 In conclusion, the present results showed that patients with maxillectomy and rehabilitation with an obturator prosthesis had good overall QoL and OFS scores. The effects of functional performance of eating in public, understandability of speech, and normalcy of diet on QoL and OFS scores have not been previously reported in the literature, and more studies are needed to confirm these findings. Longitudinal studies using the same scales as in the present study through the various phases of illness, treatment, and rehabilitation might clarify the present findings.
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References 1. Yanamoto S, Yamada S, Takahashi H, et al: Benefits of maxillectomy with internal dissection of the masticator space by trans-
22.
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Q4
841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896
9
SEIGNEMARTIN ET AL
897 898 899 900 901 902 903 904 905 906 907 908
Q5
23. Kumar P, Alvi AH, Rao J, et al: Assessment of the QOL in maxillectomy patients: A longitudinal study. J Adv Prosthodont 5:29, 2013 24. Vartanian JG, Carvalho AL, Yueh B, et al: Brazilian-Portuguese validation of the University of Washington QOL Questionnaire for patients with head and neck cancer. Head Neck 28:1115, 2006 25. List MA, Sterr RC, Lansky SB: A performance status scale for head and neck cancer patients. Cancer 66:564, 1990 26. Hassan SJ, Weymuller EA Jr: Assessment of QOL in head and neck cancer patients. Head Neck 15:485, 1993 27. Pupo D, Bussoloti FI, Liquidato BM, et al: A proposal for a practical method of sialometry. Rev Bras Otorinolaringol 68: 219, 2002 28. Camargo KAN, Pupo D, Bussoloti FI: Sialometria. Acta Orl 23: 129, 2005
29. Conceic¸~ao MD, Marocchio MS, Fagundes RL: Sialometric technique for use in clinical practice. Rev Assoc Paul Cir Dent 60: 300, 2006 (in Portuguese). 30. Sood AJ, Fox NF, O’Connell BP, et al: Salivary gland transfer to prevent radiation-induced xerostomia: A systematic review and meta-analysis. Oral Oncol 50:77, 2014 31. Navazesh M, Kumar SKS: Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 139(suppl 2):35S, 2008 32. Sullivan M: The expanding role of dental oncology in head and neck surgery. Surg Oncol Clin North Am 13:37, 2004 33. Eades M, Murphy J, Carney S, et al: Effect of an interdisciplinary rehabilitation program on QOL in patients with head and neck cancer: Review of clinical experience. Head Neck 35:343, 2013
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Q6
909 910 911 912 913 914 915 916 917 918 919 920