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Evaluation of the quality of life of patients with maxillofacial defects after prosthodontic rehabilitation: A cross-sectional study

1 Department of Prosthodontics Crown and Bridge, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, MAHE Manipal, Mangalore, Karnataka, India
3 Department of Radiation Oncology, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India

Date of Submission30-Jun-2020
Date of Decision29-Aug-2020
Date of Acceptance30-Sep-2020
Date of Web Publication23-Oct-2021

Correspondence Address:
Vidya K Shenoy,
Department of Prosthodontics Crown and Bridge, A.J. Institute of Dental Sciences, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_889_20

 > Abstract 

Context: Oral cancer surgery leads to hard- and soft-tissue loss which can affect the quality of life of the individuals. Maxillofacial prosthodontics focuses on optimizing the disrupted oral function of individuals whose rehabilitation will serve as a psychosocial therapy.
Aim: The aim of this study was to assess the oral health-related quality of life (OHRQoL) after the maxillofacial prosthetic rehabilitation following cancer resection surgery.
Settings and Design: The sample comprised 15 oral cancer patients who agreed to maxillofacial prosthesis (MFP) after surgery.
Materials and Methods: Oral function and OHRQoL were evaluated pre- and postmaxillofacial prosthetic rehabilitation. The masticatory function, swallowing function, and articulatory function were evaluated. The OHRQoL was evaluated by OHIPJ-14 questionnaire. Descriptive methods such as frequency, percentage, mean, and standard deviation were calculated.
Statistical Analysis: Descriptive statistics was used to analyze the results.
Results: A statistically significant difference was observed between prescores and postscores of dysphagia score (P = 0.05) and OHIP-J14 score (P = 0.00). No statistically significant differences were evident in perceived chewing ability (P = 0.29) and intelligibility score (P = 0.43). A statistically significant difference was evident in the prescore and postscore of OHIP-J14 subscales: functional limitations (P < 0.05), physical pain (P < 0.05), psychological discomfort (P < 0.05), physical disability (P < 0.05), psychological disability (P < 0.05), and handicap (P < 0.05), before and after maxillofacial prosthetic treatment except for social disability (P > 0.05).
Conclusion: OHRQoL significantly improved with maxillofacial prosthetic rehabilitation.

Keywords: Maxillofacial prosthetic rehabilitation, oral cancer, quality of life

How to cite this URL:
Matapathi N, Shenoy VK, Shenoy R, Miranda GA, Upadhya M, Mehendale A, Bangera B, Shenoy K K. Evaluation of the quality of life of patients with maxillofacial defects after prosthodontic rehabilitation: A cross-sectional study. J Can Res Ther [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=329057

 > Introduction Top

Oral deformities associated with surgical resection of oral cancer result in physical, functional, and esthetic disturbances.[1],[2],[3],[4] The associated social taboo can result in social negligence and negative personality traits.[3],[4]

Prosthetic treatment requires less time and it allows the surgical site to be examined for any recurrence.[3],[5],[6],[7],[8] Prosthesis can be considered in cases of advanced age, poor health, severe deformity, or irradiated tissue.[9]

Surgical deformities and impaired prosthetic functioning may affect the quality of life in general.[3],[5],[10],[11],[12] Therefore, a need arises to assess the oral health-related quality of life (OHRQoL) in patients after maxillofacial prosthetic rehabilitation.

 > Materials and Methods Top

Fifteen subjects who reported for maxillofacial prosthesis (MFP) following surgical resection for oral cancer were enrolled in this cross-sectional study. All study-related procedures were approved by the institutional review board and ethics committee.

Each subject received a written and oral description of the study and written informed consent was obtained prior to inclusion in the study. Inclusion criteria for this study were subjects who reported for MFP after surgery and radiation therapy in the maxillofacial region and those who were able to understand and respond to test questionnaires.

Intraoral and extraoral examinations were carried out and the profile of the defect area was tabulated [Table 1]. The defect area was classified as maxillary, mandibular, tongue, or oral floor based on Aramany classification[13] and CAT classification.[14]
Table 1: Profiles of the defect area

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Occlusion was evaluated using Eichner classification. This index is based on the number of occlusal support zones which consist of occlusal contacts of the existing natural teeth or fixed prosthesis in the premolar and molar regions.[15]

Oral function including masticatory function (chewing ability), swallowing function (dysphagia score), articulatory function (intelligibility), and oral health impact profile (OHIP) was evaluated before prosthesis placement and 1 month after final adjustments of the prosthesis.

Subjective assessment of masticatory function was done using reported chewing ability questionnaire.[16] The questionnaire consisted of six questions based on the chewing efficiency with relevant choices.

Swallowing function was evaluated by dysphagia score. There were five scores from 0 to 4: 0 – being no dysphagia to 4 – being no passage, unable to swallow anything.[17]

Articulatory function was assessed using Frenchay Dysarthria Assessment, Part 8: intelligibility.[18] The patient was asked to talk for 5 min or the examiner would engage the subject in conversation for 5 min about the job, hobbies, and relatives and so on. The rating scale consists from 1 (no noticeable differences) to 5 (unintelligible).

OHIP assessment was done using OHIP-J14 which is the Japanese short version of questionnaire consisting of 14 questions based on OHRQoL.[19] It was translated into local vernacular languages. The instructions regarding filling of questionnaires were explained to the subjects. Subjects were asked to complete the questionnaires based on their experience. The participants were asked how frequently they have experienced the impact of that item using a scale coded 4 – very often, 3 – fairly often, 2 – occasionally, 1 – hardly ever, and 0 – never. The OHIP characterizes the seven domains as follows: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap.[19]

After the assessment of the above, the maxillofacial prosthetic treatment was performed. One month after the placement of MFP, oral functions were evaluated again.

Statistical analysis

Pre- and postscores of the OHIP and chewing ability questionnaire were analyzed using paired t-test to evaluate the improvement in OHRQoL and masticatory function, respectively. Intelligibility scores (P = 0.05) and dysphagia scores (P = 0.43) were analyzed using the Chi-square test to assess the articulatory function and swallowing function, respectively.

The explanatory variables were sex, age, defect area, occlusion, OHIP score, chewing ability score, dysphasia score, and intelligibility score. Collective data were analyzed by descriptive and inferential methods. Descriptive methods such as frequency, percentage, mean, and standard deviation were calculated.

Defect areas were categorized into a maxillary defect and a mandibular defect group, and occlusion was categorized as either molar support present (Group A or B) or absent (Group C). The association between these factors and OHRQoL before (prescore) and after (postscore) were compared using unpaired independent Student's t-test.

The data were processed with a statistical package for social science version 22 for windows statistical software (SPSS Inc., Chicago, IL, USA).

 > Results Top

Fifteen participants including 6 men (average age 44.11 + 19.56) and 9 women (average age 50.33 + 18.63) were enrolled in the study. The average age of all participants was 46.60 ± 18.78 (19–72). Of these participants, 11 were categorized into a maxillary defect group and the other four were categorized into a mandibular region defect group. All patients had undergone oral cancer resection surgery, and none had undergone reconstructive surgery and postsurgical radiation therapy. The occlusion was classified based on the Eichner index for occlusal supporting zones. Nine patients were designated as Group B and 6 were grouped as C [Table 1].

The results of the chewing ability score are shown in [Figure 1]. Prescore and postscores did not show a statistically significant difference in both maxillary and mandibular defect groups (P > 0.05).
Figure 1: Perceived chewing ability scores (mean ± standard deviation). Mean ± standard deviation of chewing ability before and after Maxillofacial prosthetic rehabilitation (MFPR) are 4.33 ± 1.23 and 3.86 ± 0.83, respectively

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The results of dysphagia score are shown in [Figure 2]. A statistically significant difference was observed between pre- and postdysphagia scores (P = 0.05) and Chi-square value was 9.47. In pretreatment dysphagia scores, 40% of participants were able to swallow semisolids, 53.3% were able to swallow liquids and one participant had total dysphagia. After maxillofacial rehabilitation, 40% of the participants were able to swallow some solid foods, 46.66% were able to swallow semisolids, and 13% were able to swallow liquids only. This suggests a significant improvement in swallowing ability of the participants following prosthetic rehabilitation.
Figure 2: Dysphagia scores. The graph depicts the results for pre- and postpercentage of distribution of dysphagia score

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The results from the articulatory test are shown in [Figure 3]. In preprosthetic phase 4, participants had abnormal, but intelligible speech, in 5 participants' speech, it was severely distorted and in 5 participants, occasional words were decipherable. After maxillofacial rehabilitation, 7 participants had no abnormality in the speech, in 5 participants' speech, it was abnormal but intelligible, and in 3 participants' speech, it was severely distorted. The improvement in speech intelligibility index after prosthetic rehabilitation was not statistically significant (P > 0.05) and Chi-square value was 5.87.
Figure 3: Intelligibility scores. The graph depicts the results for pre- and postpercentage of distribution of intelligibility score

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The mean OHIP-J14 postprosthetic scores reduced significantly compared to the prescore suggesting an improvement in the OHRQoL (P < 0.05). The mean score of the OHIP-J14 and the subscale score before and after maxillofacial rehabilitation are shown in [Table 2] and [Table 3].
Table 2: OHIPJ14 results

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Table 3: OHIPJ14 subscale

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For the subscales of OHIP-J14, statistically significant differences were observed for functional limitations (P < 0.05), physical pain (P < 0.05), psychological discomfort (P < 0.05), physical disability (P < 0.05), psychological disability (P < 0.05), and handicap (P < 0.05), before and after maxillofacial prosthetic treatment, except for social disability (P > 0.05) which showed no statistically significant differences after the prosthetic rehabilitation [Table 3].

The unpaired independent Student's t-test applied between the factors such as gender, type of occlusion and type of defect, and OHRQoL depicted no strong correlation between any of the factors [Table 4] and [Table 5].
Table 4: Correlation of dysphagia with gender, defect, and occlusion

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Table 5: Correlation of intelligibility with gender, defect, and occlusion

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 > Discussion Top

OHRQoL in patients with maxillofacial tumors is a multidimensional element that needs to be addressed by researchers in health-care sectors. This could be attributed not only to the diagnosis of disease itself but also to significant functional and esthetic impairment as a result of therapeutic interventions. Hence, emotional functioning has a significant impact on OHRQoL.[20] The present study investigated the effect of maxillofacial prosthetic treatment after the oral cancer surgery on OHRQoL of patients as limited studies address the quality of life after maxillofacial prosthetic rehabilitation.

In the present study, 15 subjects were investigated. To assess the impact of the maxillofacial prosthetic rehabilitation on OHRQoL, oral functions were evaluated by self-perceived chewing ability (PCA) index, dysphagia score, intelligibility score, and OHIP-J14 questionnaires before and after prosthetic rehabilitation, which enabled simultaneous evaluation of the changes in the OHRQoL.

In the current study, 11 subjects (73.3%) had maxillary defects and 4 (26.7%) had a mandibular defect. The study did not come across subjects with defects in the tongue and oral floor. In addition, 11 (73.3%) subjects were partially dentate and 4 (26.7%) were completely edentulous individuals.

Pre- and post-PCA index showed no statistically significant improvement in the PCA index after the maxillofacial prosthetic rehabilitation. Of the 15 subjects, 12 answered “sometimes” they feel pain during chewing after prosthetic rehabilitation. In this study, 11 subjects had maxillary defects, which is probably why significant improvement is not seen in the chewing ability score. In maxillary defects, an oronasal fistula after surgery leads to functional problems; however, normal function may be restored as long as the tissue-deficient area is replaced and obturated.[21] Furthermore, the small sample size may have affected the results.

The coordination of the tongue, check, and lips plays a major role in swallowing function. Surgical defects after oral cancer surgery cause interference of lip closure owing to the disharmony of the anterior teeth and altered maxillofacial form difficulty retaining intraoral negative pressure and expansion of the tongue space.[22],[23] This in turn affects the swallowing function. Comparison of pre- and post-dysphagia score showed a significant improvement (P = 0.05) in the swallowing function of the patient after maxillofacial prosthetic rehabilitation. However, the study did not come across patients involving the tongue, lip, and soft palate. MFP in general replaces the lost tissue and tooth structure thereby improving facial form and also improves the oral function.

The present study showed no statistically significant improvement in the intelligibility of the patient after maxillofacial prosthetic fabrication. As majority of defects were maxillary defects involving the hard palate, the speech may have got affected significantly. The results were consistent with the study conducted by Rieger et al.,[24]which demonstrated that poorer functioning of an obturator in what would be considered clinically poorer aeromechanical and perceptual speech outcomes reflected by patient perception. Hence, it is essential to consider the influence of background patient variables to analyze the patient perception and speech ability. The factors affecting the speech could be dry mouth, mechanical components such as clasps, and retention of the prosthesis which have not been assessed in the current study. Poor intelligible speech results imply that a patient might be at risk for poor adjustment and compromised social interaction and therefore might be used as an indicator for psychosocial intervention before interpersonal well-being is affected to a measurable impairment.[24]

Complete restoration of function after maxillofacial rehabilitation is considered to be difficult because of the changes in the mobility pattern of the mandible and the tongue. Furthermore, alterations in soft tissue form including the muscle attachments may interfere in attaining good end results.

The OHIP was developed with the aim of providing a comprehensive measure of self-reported dysfunction, discomfort, and disability attributed to oral conditions.[25] The OHIP is concerned with impairment and three functional status dimensions (social, psychological, and physical) which represent four of the seven quality-of-life dimensions proposed by Patrick and Bergner.[26] Hence, it excludes perceptions of satisfaction with oral health, changes in oral health, prognosis, or self-reported diagnoses. Furthermore, the OHIP aims to capture impacts that are related to oral conditions in general, rather than impacts that may be attributed to specific oral disorders or syndromes.[27]

Locker's model of oral health was used to define seven conceptual subscales of impact: functional limitation (e.g., difficulty chewing), physical pain (e.g., sensitivity of teeth), psychological discomfort (e.g., self-consciousness), physical disability (e.g., changes to diet), psychological disability (e.g., reduced ability to concentrate), social disability (e.g., avoiding social interaction), and handicap (e.g., being unable to work productively).[28]

The subscales of OHIPJ14 assessment reveal the improvement of patient OHRQoL in all aspects such as functional limitations (P < 0.05), physical pain (P < 0.05), psychological discomfort (P < 0.05), physical disability (P < 0.05), psychological disability (P < 0.05), and handicap (P < 0.05), except social disability (P > 0.05). Thus, improving a patient's OHRQoL with MFP may be possible even though only one oral function is can be improved.

OHIP items relating to “been bitirritable with other people” and “had difficulty doing your usual job” showed no significant changes. This is in line with the study conducted by Irish et al.[12] and Kornblith et al.,[6] who demonstrated that the patients with increasing difficulties with MFP function reported increased disease impact, depression, loss of behavior or emotional control, and decreased positive effect.

Good prosthesis function is a critical factor responsible for improved quality of life. However, in the current study, prosthesis quality has not been evaluated. Other important factors such as socioeconomic variables and psychological state which may have a significant effect on the quality of life are also not considered. Small sample size and unequal distribution of defect regions may be other limitations which may have affected the outcome of the study.

Masticatory function, swallowing function, and articulatory function were each determined to have an influence on the OHRQol. The hypothesis that the maxillofacial prosthetic rehabilitation had no influence on the OHRQoL is rejected. Future research should consider longitudinal, multicentric studies with various socioeconomic factors, a larger sample size, and various prosthesis designs to help improve patient's quality of life.

Construction of prosthesis that substitutes the soft and hard tissue reduces the morbidity and recovery time. These maxillofacial prostheses require time and skill to satisfy the functional and esthetic needs of the patient. To fulfill these needs, advanced techniques such as computer-aided designing and machining, implant-supported prostheses, three-dimensional printing, and digital imaging can be adapted.[29],[30] Digital oral impressions can reduce the time and steps involved in the fabrication, further increase the patient acceptance and replicate the patient characteristics accurately.[31],[32],[33] Hence, they can be a viable and reliable alternative to conventional methods.[31],[34]

Fixed maxillofacial prostheses improve patient's confidence and self-assurance and overall enhance the quality of life.[35] Placement of implants in patients undergoing cancer resection can be challenging due to factors such as impaired salivary flow, poor oral hygiene, and immune-compromised states. Since studies have shown successful implant therapy in immune-compromised HIV-positive patients with stable diseases,[36],[37] the implant prosthetic rehabilitation can be a reliable option. Hence, the advanced treatment plans and techniques can also be considered to enhance the OHRQoL of patients.

 > Conclusion Top

Based on the findings of this clinical study, the following conclusions were drawn:

  1. In individuals with oral cancer who have undergone maxillofacial prosthetic treatment, swallowing function improved significantly. However, masticatory and articulatory function did not improve significantly.

The OHRQoL of participants was improved significantly after maxillofacial prosthetic treatment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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