Dental Status and Quality of Life in Long-Term Head and Neck Cancer Survivors

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

The impact of hospitalization on dental plaque accumulation: an observational study

AIM

To investigate the effect of hospitalization on oral health as assessed by dental plaque.

MATERIALS AND METHODS

Observational study in a critical care unit (CCU). Participants were recruited within 24 h of admission. Dental plaque amount was assessed at baseline, 1 and 2 weeks using the Debris index-soft deposits (Greene & Vermillion 1960).

RESULTS

Fifty participants were recruited with 36 available for outcome assessment at 1 week and 10 at 2 weeks. The principal reason for losses was early discharge with no evidence of a difference between patients present only at baseline and those present at 1 week. The median value for dental plaque at baseline was 4 (95% CI: 4, 6). The median dental plaque increase from baseline to week 1 was 1.5 (95% CI: -1, 4), and this was statistically significant (p = 0.04). The median increase from week 1 to week 2 was 1.0 (95% CI -8, 6) and not statistically significant (p = 0.68).

CONCLUSIONS

Oral health as assessed by dental plaque deteriorates following hospitalization in CCU. Such change could lead to impairment of quality of life and well-being as well as to increasing the risk of important healthcare-associated infections such as nosocomial pneumonia.

A systematic review of head and neck cancer quality of life assessment instruments

Although quality of life (QOL) is an important treatment outcome in head and neck cancer (HNC), cross-study comparisons have been hampered by the heterogeneity of measures used and the fact that reviews of HNC QOL instruments have not been comprehensive to date. We performed a systematic review of the published literature on HNC QOL instruments from 1990 to 2010, categorized, and reviewed the properties of the instruments using international guidelines as reference. Of the 2766 articles retrieved, 710 met the inclusion criteria and used 57 different head and neck-specific instruments to assess QOL. A review of the properties of these utilized measures and identification of areas in need of further research is presented. Given the volume and heterogeneity of QOL measures, there is no gold standard questionnaire. Therefore, when selecting instruments, researchers should consider not only psychometric properties but also research objectives, study design, and the pitfalls and benefits of combining different measures. Although great strides have been made in the assessment of QOL in HNC and researchers now have a plethora of quality instruments to choose from, more work is needed to improve the clinical utility of these measures in order to link QOL research to clinical practice. This review provides a platform for head and neck-specific instrument comparisons, with suggestions of important factors to consider in the systematic selection of QOL instruments, and is a first step towards translation of QOL assessment into the clinical scene.

Oral health is an important issue in end-of-life cancer care

PURPOSE

This study aims to assess the prevalence of oral morbidity in patients receiving palliative care for cancers outside the head and neck region and to investigate if information concerning oral problems was given.

METHODS

Patients were recruited from two Norwegian palliative care inpatient units. All patients went through a face-to-face interview, completed the Edmonton Symptom Assessment System (ESAS) covering 10 frequent cancer-related symptoms, and went through an oral examination including a mouth swab to test for Candida carriage.

RESULTS

Ninety-nine of 126 patients (79 %) agreed to participate. The examined patients had a mean age of 64 years (range, 36-90 years) and 47 % were male. Median Karnofsky score was 40 (range, 20-80) and 87 % had metastatic disease. Estimated life expectancy was <3 months in 73 %. Dry mouth was reported by 78 %. The highest mean scores on the modified 0-10 ESAS scale were 4.9 (fatigue), 4.7 (dry mouth), and 4.4 (poor appetite). Clinical oral candidiasis was seen in 34 % (86 % positive cultures). Mouth pain was reported by 67 % and problems with food intake were reported by 56 %. Moderate or rich amounts of dental plaque were seen in 24 %, and mean number of teeth with visible carious lesions was 1.9. One patient was diagnosed with bisphosphonate-related osteonecrosis of the jaw. Overall, 78 % said they had received no information about oral adverse effects of cancer treatment.

CONCLUSION

Patients in palliative care units need better mouth care. Increased awareness among staff about the presence and severity of oral problems is necessary. Systematic information about oral problems is important in all stages of cancer treatment.

The relationship between weight loss and health-related quality of life in persons treated for head and neck cancer

PURPOSE

This study explores the relationship between weight loss, health-related quality of life (HRQOL), and symptom burden in patients treated for head and neck cancers.

METHODS

Participants completed the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) and the Memorial Symptom Assessment Scale (MSAS) pre-treatment, mid-treatment, and post-treatment. Weights were recorded prior to treatment and at the post-treatment follow-up visit, and percentage weight loss was tabulated. Relationships between weight loss, HRQOL, and symptom burden were evaluated using the nonparametric Spearman rho. A simple linear regression model was developed to examine the influence weight loss has on HRQOL in a predictive manner.

RESULTS

Average weight loss per patient was 12 lb with a modal value of 19. Weight loss was found to be significantly correlated with decreases in physical well-being, functional well-being, the Head and Neck specific subscale, and composite QOL scores. No significant correlations were found between weight loss and symptom burden as measured by the MSAS. Linear regression suggested that a 10% decrease in baseline weight resulted in a 19% decrease in the FACT-H&N score.

CONCLUSION

The strong association between weight loss and HRQOL supports the importance of efforts to prevent weight loss via patient education, aggressive monitoring, and immediate intervention to stop or reverse weight loss during treatment. New approaches to the weight loss and wasting experienced by patients should be developed and tested.

The impact of hospitalization on oral health: a systematic review

BACKGROUND

Poor oral health of hospitalized patients is associated with an increased risk of hospital-acquired infections and reduced life quality.

OBJECTIVES

To systematically review the evidence on oral health changes during hospitalization.

DATA SOURCES

Cochrane library, Medline, OldMedline, Embase and CINAHL without language restrictions.

STUDY ELIGIBILITY CRITERIA

Observational longitudinal studies.

DATA APPRAISAL AND SYNTHESIS METHODS

Two independent reviewers screened studies for inclusion, assessed the risk of bias and extracted data. Risk of bias was assessed using the Newcastle-Ottawa assessment scale. A narrative synthesis was conducted.

RESULTS

Five before and after studies were included. The data suggest a deterioration in oral health following hospitalization with an increase in dental plaque accumulation and gingival inflammation and a deterioration in mucosal health.

LIMITATIONS

While before and after studies are at a general risk of bias, other specific study characteristics were judged to have a low risk of bias. However, methodological issues such as unvalidated outcome measures and the lack of assessor training limit the strength of the evidence.

CONCLUSION

Hospitalization is associated with a deterioration in oral health, particularly in intubated patients.

Limited mouth opening after primary therapy of head and neck cancer

OBJECTIVES

Patients after surgery and radiation/chemoradiation for treatment of head and neck cancer often suffer from oral complications. These problems may be caused by surgery and radiation. Patients complain, for example, of swallowing problems and limited mouth opening (trismus).

METHODS

The maximal interincisal mouth opening (MIO) was measured in patients treated with surgery and radiation/chemoradiation for head and neck cancer at the Department of Otorhinolaryngology at the University of Rostock. These patients also completed a 20-item questionnaire concerning nutritional, sensual, and speech disorders and pain.

RESULTS

One hundred one patients (16 female and 85 male) returned the questionnaire and were included in the study. About 50% of the patients had a limited mouth opening (<36 mm); patients with oropharyngeal cancer had a significant higher risk for trismus (p = .024) than patients with other head and neck cancers, especially compared to patients with laryngeal cancer (p = .013). The questionnaire showed that especially patients with oral cancer report about problems with opening the mouth (73%), eating (65%), drinking (73%), xerostomia (92%), speech disorders (68%), and voice (62%). Patients with laryngeal cancer only reported about problems with xerostomia (62%), speech (83%), and voice (90%), similar to patients with pharyngeal cancer.

CONCLUSIONS

About half of the patients who underwent primary treatment for oral and oropharyngeal cancer developed trismus and reported about problems with opening the mouth, eating, drinking, dry mouth, voice, and speech. Trismus has a negative impact on quality of life and should be a focus in the postoperative management of patients with oral and oropharyngeal cancer, and, if diagnosed, special treatment should be initialized.

Mastication in patients treated for malignancies in tongue and/or floor of mouth: A 1-year prospective study

BACKGROUND

People confronted with oral cancer run a high risk of deteriorated masticatory performance. Reduced masticatory function may affect quality of life and food choice. An altered food choice may result in lower intakes for key nutrients and weight loss.

METHODS

Dental state, bite force, and masticatory performance were determined in a group of 45 patients with squamous cell carcinoma of the tongue and/or floor of mouth. Measurements were performed before surgery and at various moments after surgery and/or radiotherapy.

RESULTS

Surgical intervention had a large negative impact on oral function. Radiotherapy further worsened oral function. Also, the recovery of oral function 1 year after surgery was less prominent for the surgery-radiotherapy group than for the surgery group.

CONCLUSION

Objective determination of oral function 1 year after surgery showed that patients treated for malignancies in the tongue and/or floor of mouth had significantly deteriorated masticatory performance, bite force, and dental state.

A systematic review of dental disease in patients undergoing cancer therapy

INTRODUCTION

This purpose of this systematic review was to evaluate the literature and update our current understanding of the impact of present cancer therapies on the dental apparatus (teeth and periodontium) since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies.

REVIEW METHOD

A systematic literature search was conducted with assistance from a research librarian in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 1990 and 31 December 2008. Each study was independently assessed by two reviewers. Taking into account predetermined quality measures, a weighted prevalence was calculated for the prevalence of dental caries, severe gingival disease, and dental infection. Data on DMFT/dmft, DMFS/dmfs, plaque, and gingival indexes were also gathered. The level of evidence, recommendation, and guideline (if possible) were given for published preventive and management strategies.

RESULTS

Sixty-four published papers between 1990 and 2008 were reviewed. The weighted overall prevalence of dental caries was 28.1%. The overall DMFT for patients who were post-antineoplastic therapy was 9.19 (SD, 7.98; n = 457). The overall plaque index for patients who were post-antineoplastic therapy was 1.38 (SD, 0.25; n = 189). The GI for patients who were post-chemotherapy was 1.02 (SD, 0.15; n = 162). The weighted prevalence of dental infections/abscess during chemotherapy was reported in three studies and was 5.8%.

CONCLUSIONS

Patients who were post-radiotherapy had the highest DMFT. The use of fluoride products and chlorhexidine rinses are beneficial in patients who are post-radiotherapy. There continues to be lack of clinical studies on the extent and severity of dental disease that are associated with infectious complications during cancer therapy.

A systematic review of orofacial pain in patients receiving cancer therapy

PURPOSE

We present the findings of a structured systematic review of the literature assessing orofacial pain induced by malignant disease and/or its therapy (excluding mucositis). This evaluation of the literature published after the 1989 NIH Development Consensus conference on the oral complications of cancer therapies is an effort to assess the prevalence of pain, quality of life and economic impact, and management strategies for cancer therapy-induced orofacial pain.

METHODS

A systematic medical literature search was conducted with assistance from a research librarian in MEDLINE/PubMed and EMBASE databases for articles published between January 1, 1990 and December 31, 2008. Each study was independently assessed by two reviewers with expertise in the field of oral oncology.

RESULTS

Thirty-nine studies assessed pain in the head and neck region. The measure was commonly embedded in quality of life studies. Most of these studies described pain in head and neck cancer (HNC) patients, which therefore became the focus of the report. Pain is common in patients with HNC and is reported by approximately half of patients prior to cancer therapy, 81% during therapy, 70% at the end of therapy, and by 36% at 6 months after treatment. Pain is experienced beyond the 6-month period by approximately one third of patients and is typically more severe than pre-treatment cancer-induced pain.

CONCLUSIONS

This systematic review identified the presence of pain before cancer therapy, likely attributable to the cancer; an increase in pain during therapy and the common persistence of pain following cancer treatment. Continuing research should use validated tools to prospectively assess orofacial pain, its causes and pathophysiology, and its effect on quality of life and economic impact. Clinical trials of pain management in this setting are also warranted.

Prevention and treatment of trismus in head and neck cancer: A case report and a systematic review of the literature

Introduction

Trismus, or limited mouth opening, is a well-known complication of head and neck cancer and its treatment. It may be caused by tumour infiltration into the masticatory muscles or by treatment like surgery and radiotherapy. A limited mouth opening may have a negative effect on nutrition, phonation, dental hygiene and treatment, and quality of life. The severity of this complication depends on the location of the tumour, the type of reconstruction, the total radiation dose, fractionation, and treatment techniques. If there is no intervention, these changes may be progressive and persist for life. There are no specific treatments for trismus. Current strategies emphasize prevention and, in instances of existing trismus, collaboration between health care professionals to establish pain control, prevent the progression of trismus, and restore function. The prevalence of trismus in head and neck cancer patients ranges from 5% to 38%. Despite numerous studies, reliable data on the aetiology of trismus and appropriate treatment for it are scarce.

Case report

We describe a patient with squamous cell carcinoma of the oropharynx who developed trismus after surgery and radiotherapy. A multidisciplinary treatment strategy including analgesics, regional blocks, hyperbaric oxygenation therapy, external dynamic bite opener and physiotherapy, increased the mouth opening from 5 mm to 22 mm, however, the patient still suffered from xerostomia and had problems with intake of solid food.

Material and methods

A systematic literature search (starting January 1., 1980, and ending June 1., 2009) was performed to identify evidence-based interventions for the treatment of trismus in head and neck cancer patients. A total of 244 articles were identified from the databases. Of these, eight were excluded because of the absence of an English abstract and 214 were excluded because they were of marginal relevance to the inclusion criteria. The remaining 22 articles were evaluated independently by two experts using the Scottish Inter-collegiate Guidelines Network criteria for quality and evidence.

Results

There were few studies of good methodological quality on this topic. Two systematic reviews and two RCTs were identified. The other reports involved cohorts, case series, and expert opinions.

Discussion

Evidence in the form of clinical studies on therapeutic interventions is scarce. Numerous pharmacological treatment modalities have been described, but few are supported by the results of comparative trials involving control groups. Few studies have documented therapeutic effects for longer than a year. Better evidence was found for non-pharmacological methods, especially for physical therapy with passive and active stretching exercises, an important first-line strategy. The interincisal distance criterion for trismus varies between authors from 15 to 40 mm, which renders comparison between studies difficult. The absence of a standardized assessment protocol may also have contributed to variation between studies. An interincisal distance of 35 mm has been proposed as a definition of trismus. Explicit and precise treatment algorithms could not be established based on the available literature. However, a coordinated multidisciplinary approach in order to estimate and understand patient dysfunction is recommended; a systematic treatment plan should result in good symptom control and patient care. Prevention of trismus is more desirable than treatment for trismus.

The potential of proton beam radiation therapy in head and neck cancer

A group of Swedish oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy. The estimations have been based on current statistics of tumour incidence, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours and normal tissues. In head and neck cancer, including thyroid cancer, it is assessed that at least 300 patients annually will gain sufficiently from proton beam therapy, both to improve tumour control and to decrease toxicity to compensate for the increased treatment costs using protons.

Botulinum toxin for radiation-induced facial pain and trismus

OBJECTIVE

To report the efficacy of botulinum toxin A for radiation-induced pain, trismus, and masticator spasm in head and neck cancer.

PATIENTS AND METHODS

This prospective nonrandomized study included patients in complete remission with radiation-induced pain and trismus with or without masticator spasms. Fifty units of Botox (Allergan) or 250 units of Dysport (Ipsen) were injected transcutaneously into the masseter muscles. Jaw opening was measured and patients answered 20 questions about jaw opening, pain, and cramps, before injection at 1 month.

RESULTS

Nineteen patients (7 women, 12 men) were included. Median time after radiation therapy was 5 years (range, 11 months to 22 years). At 1 month, no significant increase in jaw opening was recorded. Improvement was noted in the functional domain (P = 0.004), for pain (P = 0.002) and cramps (P = 0.004), but not in the social (P = 0.83) or emotional (P = 0.43) domains. No side effects occurred.

CONCLUSIONS

Botulinum toxin did not improve trismus but significantly improved pain scores and masticator spasms (oromandibular dystonia).

Quality of life research in head and neck cancer: a review of the current state of the science

Quality of life (QOL) has become an increasingly important outcome measure for patient's undergoing treatment for a wide array of illnesses. QOL is a global construct that reflects a patient's general sense of well being. It is by definition multi-dimensional and reflective of the patient's point of view. Health related issues are among the many factors that may influence QOL. Since head and neck cancer (HNC) affects structures that are critical for normal functions such as speech and swallowing, and treatment may lead to deformities that adversely impact psychosocial functioning, there is particular interest in assessing QOL in this cohort of patients. In order to interpret the HN QOL literature, it is important to have an understanding of the significance and limitations of QOL assessments in the head and neck patient population as well as an appreciation for the currently available measurement tools. Unfortunately, the HNC QOL literature has many limitations including: small sample size, lack of prospective data and poor study design. None-the-less, important insights can be obtained by review of the current literature. First, it is important that QOL studies be reported in such a way as to provide clinically meaningful data to clinicians. Linking measurements with clinical benchmarks is one way to accomplish this goal. In addition, both general and HNC specific measures are needed in order to provide a comprehensive assessment of global health and tumor specific issues. In general, QOL declines immediately after therapy and returns toward baseline by 1 year. Several factors have been identified that may predict for worse QOL outcomes including: the presence of a feeding tube, co-morbid disease, tracheotomy, site and stage. Data correlating QOL with functional outcome and symptom burden fails to demonstrate a consistent relationship. This may be attributed to methodological issues in study design or the patient's ability to adapt to functional and symptom control problems. Whether routine use of QOL measures in the clinical setting is beneficial to patients has yet to be determined. Further studies are warranted as currently available instruments may not be valid for repeated clinical use.

Monitoring the physical health of cancer survivors: a survivorship-focused medical history

Cancer survivors frequently visit their primary-care physicians, as well as oncology specialists, for follow-up care. There is a need to monitor these survivors for the late physical effects of cancer, yet few health care providers have received training in how to do this. This article provides guidance on how to take a cancer survivor-directed medical history to facilitate the elicitation of relevant exposures, family history, and symptoms that may be related to the late effects of cancer therapy.

Psychological responses and support needs of patients following head and neck cancer

The patient with head and neck (H&N) cancer is prone to psychological distress immediately following diagnosis and during the treatment phase. Lowered mood is typical and tends to extend beyond the treatment phase. There is little evidence for a specific treatment method predicting a characteristic psychological response. Rather, patients' reactions vary widely according to fears of recurrence, health beliefs, personality, coping and available support. Patient reports of quality of life show a return to pre-treatment status after a year but are determined to some degree by initial depression levels and dispositional factors such as optimism. Information provided to patients (e.g. leaflets, booklets of written guidance) by specialist treatment centres about the disease and its management require sustained effort in their design and distribution. Our understanding of patient responses to this disease has improved and has assisted in the development of psychological interventions. Controlled trials will provide important evidence of the components, effects and sustainability of these experimental programmes, and improve overall care plans for this often neglected patient group.