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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 3  |  Page : 228-233

Evaluation of oral health related quality of life in subjects diagnosed with head and neck malignancies undergoing chemotherapy, radiotherapy, and surgery

1 Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chhattisgarh, India
2 Department of Oral Medicine and Radiology, Swami Devi Dayal Hospital and Dental College, Punchkula, Haryana, India

Date of Submission01-Apr-2019
Date of Acceptance16-May-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Ravleen Nagi
Department of Oral Medicine and Radiology, Swami Devi Dayal Hospital and Dental College, Punchkula, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_71_19

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Background: Oral cancer is a significant public health problem in India, which accounts for 90% of all head and neck (H and N) cancers and 3--4% of malignancies. It has mutifactorial etiology, and tobacco usage in smoke and smokeless form is considered to be a major risk factor. The prevalence of smoking habit is related to lifestyle, various methods were employed earlier to interpret and analyze, among them Oral Health Impact Profile-14 questionnaire is one of the most accepted instrument to analysis. Aim and Objective: To evaluate oral health-related quality of life (OHRQoL) in subjects undergoing chemotherapy, surgery, and radiotherapy.The objective of the study was to evaluate OHRQoL in H and N cancer patients using Oral Health Impact Profile-14 questionnaire. Materials and Methodology: A descriptive questionnaire based cross-sectional study of 4 months involving 50 patients undergoing treatment of H and Natcancer Hospital, Raipur city, were included.OHRQoL was assessed by OHIP-14 questionnaireand Chi-square test was used to determine statistical significant difference for the responses given by H and N cancer subjects. Results: 62.5%patients were unable to perform daily functions because of problem with their teeth and denture. Males with mean age of 55 years were found to have poorer quality of life than females. Conclusion: The OHIP-14 questionnaire proved to be reliable and valid tool for assessment of OHRQoLof cancer patients. It should be considered in the treatment protocol of cancer patients to prevent the treatment related oral health complications and for their optimal well-being.

Keywords: Cancer, oral health impact profile, quality of life, tobacco

How to cite this article:
Naidu GS, Shukla S, Nagi R, Jain S, Makkad RS. Evaluation of oral health related quality of life in subjects diagnosed with head and neck malignancies undergoing chemotherapy, radiotherapy, and surgery. J Indian Acad Oral Med Radiol 2019;31:228-33

How to cite this URL:
Naidu GS, Shukla S, Nagi R, Jain S, Makkad RS. Evaluation of oral health related quality of life in subjects diagnosed with head and neck malignancies undergoing chemotherapy, radiotherapy, and surgery. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2022 Dec 6];31:228-33. Available from: http://www.jiaomr.in/text.asp?2019/31/3/228/268278

   Introduction Top

Oral cancer is a significant public health problem in India, which accounts for 90%of all head and neck (H and N) cancers and 3--4% of malignancies. The incidence of H and N cancerhas increased significantly over the past 20 years and over 575,000 new oral cancer cases are annually diagnosed in the world (paranasal sinuses, nasal cavity, nasopharynx, oropharynx, mouth, hypo pharynx and larynx). The term oral cancer is used as a synonym for oral squamous cell carcinoma (OSCC), which has multifactorial etiology, smokingandalcohol are considered major risk factors andboth have synergistic effect. Other risk factors linked to oral cancer includegenetic, ultraviolet radiation, human papilloma virus, immunosuppression, andpoor oral hygiene.[1]

The World Health Organization (WHO) defines quality of life as “an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” (WHO, 1993).[2],[3] Early diagnosis andappropriate management of oral cancer cases is utmost important due to impact of pathological features of malignancy on the quality of life of patients. Delay in diagnosis leads to neural invasion and lymph node metastasis at later stages which is associated with poor patient prognosis.[4],[5],[6] [Figure 1] depicts oral health problems prevalent in the H and N cancer patients.
Figure 1: Shows impact of cancer treatment on oral health related QoL

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Most H and N cancer patients receive high-dose external beam radiation therapy (RT), often in combination with surgery and/or chemotherapy. The selection of a treatment or combination depends principally on the location of the tumor, its size, histological subtype, stage and the patient's general state of health. Surgery and RTcouldbe used alone to treat cases of non-metastatic disease (stage I and II), whereas more advanced cancers (stage III and IV) are treated by surgery in combination with radiotherapy and/or chemotherapy. It is important to bear in mind that these patients undergo aggressive surgeries which provoke aesthetic and functional alterations, thus affecting the patient's quality of life.[7],[8]

H and Ncancer patients are affected both by disease and therapy. To measure and quantify the subjective experiences is a challenging issue, so questionnaires have been designed that comprise information about the impact of oral cancer and its treatment on the quality of life.[9],[10],[11],[12],[13] This study used Oral Health Impact Profile (OHIP-14) questionnaireto assess oral health-related quality of life (OHRQoL) in H and N cancer patients undergoingchemotherapy, surgery, and radiotherapy.

   Materials and Methodology Top

A cross-sectional, observational study was conductedin the outpatient department of Radiology at Cancer Hospital in Raipur city to assess theOHRQoL, oral health status, and treatment need of 50 H and N cancer patients, aged between 50 and 70 years. Ethical clearance was obtained from the Ethical committee of the institute and duration of the study was from May 2017to July2017. Patients diagnosed with various stages of H and N cancer (squamous cell carcinoma), and who were willing to participate voluntarily wereincluded and patients unwilling to participate, denied to sign the informed consent and with metastasis were excluded from the study.

After written informed consent of the patients, the survey was carried out using OHIP-14questionnaire which consisted of questions onOHRQoL. The questionnaire was composed of sections, designed to collect general information such as personal data and sociodemographic profile of patients, that is, age, gender, occupation, place of residence, followed by general health and dental treatment needs, use and need of prosthesis, oral hygiene habits, and treatment recall visits.OHIP-14 is a 14-item instrument that focuses on four different aspects of OHRQoL (functional limitation, psychosocial disability, pain, and discomfort). Likert scale and force selection question formats were used in the survey and questionnaire.

Tenth and 13th question was asked in negative and positive ways, respectively, to respondent acquiescence. There were five response categories for each question and score was assigned for each response category (0-never, 1- hardly ever, 2-occasional, 3-very often, and 4- fairly often). Scores from the positively worded question were reversed during data processing so that the direction of all the responsesremains same. The OHIP-14 score was computed by adding up the scores of the response of the 14 questions.[Figure 2] depicts inclusion criteria of the study.
Figure 2: Depicts Inclusion Criteria of the Study

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Statistical analysis

Data gathered from completed questionnaireswas entered in a Microsoft excel spreadsheet and statistical analysis was done by using Statistical Package of Social Science (SPSS session 21, SPSS Inc., Chicago, IL, USA). Chi-square test was used to determine statistical significant difference for the responses given by H and N cancer patients.P ≤ 0.05 was considered statistically significant.

   Results Top

Fiftyquestionnaires evaluating OHRQoL of patients with H and N malignancies undergoing chemotherapy, radiotherapy, and surgery showed response rate of 60%. Overall, 42% were male and 8% were females. Based on the treatment, 25 patients were on chemotherapy (CT), 11 on chemoradiotherapy, and 6 on radiotherapy (RT). Fourpatients underwent radiosurgery and threeunderwent chemosurgery that suggested advanced stage of malignancy in sevenpatients [Figure 3].
Figure 3: Shows duration of cancer treatment to the patients

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Majority of patients were treated for 1--3 months (20 patients) and < less than 1month (15 patients) and 6 patients underwent long-term treatment of > 6 months. Based on WHO criteria for oral mucositis, 2 after H and N cancer treatment, normal oral mucosa, that is, Grade 0 OM was seen in 61.9% males and 87.5%females and Grade 1 OM in 16.7% males and 12.5% females. Oral ulcerations were seen only in the male patients, 2.4% were able to eat solid foods (Grade 2 OM), 9.5% were on liquid diet (Grade 3 OM), and remaining 9.5%had extensive ulcerations (Grade 4 OM) and for themoral alimentation was not possible.

OHIP-14 questionnaire response showed that oral impacts affecting QoL of H and N cancer patients were more prevalent in males as compared with females. In relation to functional limitation, statistical significant difference was observed for trouble in pronunciation of words (P = 0.016) and oral pain (0.026) for both genders, but showed similar level of decrease in taste sensation and difficulty in chewing food. Overall psychosocial problems were more prevalent in males, and most of them felt socially embarrassed (P = 0.002). Males were more tensed (78.6%), self-conscious (73.8%) as compared withfemales who were more irritable (75%) and unsatisfied with their life (75%) which affected their daily functioning [Table 1].
Table 1: Assessment of QoL of both genders by oral health impact profile (OHIP-14)

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Based on treatment, higher impact on QoL was seen after combination therapy, that is, chemoradiotherapy, although patients were more self-conscious (80%) after CT and were unable to relax (83%) after RT as comparedwithcombination therapy [Table 2]. Functional limitation and physical discomfort was more observed in 1--3 months of treatment, incidence of psychological impact was also more in 1--3 months, although patients were tensed even after 6 months of treatment. Patients were interrupting their meals, unsatisfied with diet, and were unable to function more in the 1--3 months of treatment [Table 3]. Results revealed that oral cancer treatment significantly affected the QoL of life of patients. Chemotherapy and its combination were associated with higher functional and psychosocial impact that was more prevalent in male patients than females.
Table 2: Impact on the QoL of treatment modalities of H&N cancer by OHIP-14 questionnaire

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Table 3: Evaluation of impact of duration of treatment on the QoL by OHIP-14 questionnaire

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   Discussion Top

The present study utilized data collected in cross-sectional sample that included structured interview schedules and clinical oral examinations. Sample questionnaire-based survey was conducted to provide estimates of clinical and subjective oral health characteristics of 50 patientsundergoing chemoradiotherapy or surgery for the treatment of various stages of H and N cancer (squamous cell carcinoma). H and N cancer ratio of males to females was 9:1, that is, more proportion of males (89.46%) were diagnosed with canceras compared withfemales (10.08%), this sex-based differences are quite apparent in study conducted by Hereniaand Acharya.[13],[14] The low prevalence of female patients in the present study may be due to their less habitation and theyrarely visited the hospital for the treatment. Moreover, incidence of head cancer (55.6%) was found to be more than the neck cancer (44.94%). According to Slade (2006), secondary analysis was conducted using data from an epidemiologic study of 1,217 people aged above 60 years in South Australia, it was found that sex, ethnicity, and age were associated with clinical presentation and patient reported symptoms.[15]

QoL has been defined as “the degree to which a person enjoys the important possibilities of life.” OHRQoL is multidimensional assessment of oral functioning and well-beingthat can influence individualphysically, psychologically, as well as daily functional activities. Complications ofcancer treatment havebeen shown to have high impact on patients' psychological profile mainly on their self-esteem, self-image, and patients often feel sociallyembarrassed. Oral health status such as chewing, speaking, laughing, and appearance can be impaired by loss of natural teeth by surgery or radiotherapy. Social status, communication, and aesthetics may be more important than biting and chewing, and are considered as main determinants of an individual's subjective need for replacement of the missing teeth.[6]

Pinar et al. stated that occupation isan independent risk factor in the development of H and N cancer; they found that frequency of occurrence of nasopharyngeal and oral cancers is more in high risk jobs such as agriculture, industries of construction, wood mining, etc., Similarly, in our study, there was higher number of elementary workers as compared with other occupations. The most important feature of occupational diseases is that they are preventable.[16] Therefore, the most effective way to treat occupational cancer is to prevent it by removing carcinogenic agents from the work environment. Simple procedures, such as wearing a mask, may greatly reduce the morbidity and mortality due to occupational H and N cancer.[14],[15],[16],[17] The primarytreatment goal of a physician is to improve QoL of patients bydiagnosing and treating cancers at an early stage, to restore functional anatomy of an affected area, andto reduce subsequent complications. In this study, cancer was mostly seen in older age group (>50 years) which could be due to total negligence both by the patient and their family and delay in receiving the appropriate treatment. Patients in the age group of 40--49 years received more chemotherapy as compared with radiotherapy while >60 years received more of radiotherapy as compared with chemotherapy. This could be due to the fact that in younger age group the family was more supportive and they could afford the cost of treatment but in older patientscancer progresses to advanced stage, so palliative treatment was preferred to maintain optimal QoL as long as possible.[18],[19],[20],[21],[22],[23] Ng et al.[20] suggested that a multidisciplinary approach is required to optimize the balance between the goals of organ preservation and long-term cure. The roleof chemotherapy in H and N cancers has recently expanded as a result of increasing evidence in the induction and postoperative setting.

Various scientists havestated that the growing recognition of quality of life is an important outcome of dental care and has created a need for a range of instruments like the OHIP-14 (a 14-item questionnaire) to measure oral HRQoL. This study was aimed to derive a subset of items that measured impact of treatment induced oral conditions on the well-beingof H and N cancer patients.[24],[25],[26],[27] Studies have compared (cross-sectional comparison) the validity ofOHIP-14 and oral impacts on daily performance (OIDP) as measures of oral HRQoL in patients with xerostomia.[15],[28],[29] The findings suggested that the OHIP-14 measure has good reliability, validity, and precision. In the present study, the most affected OHIP measure was “functional limitation” prevalent in 51.1% of patients, who very often experienced difficulty in pronouncing words and worsened sense of taste.[30],[31],[32] The findings of the study were consistent with the study by Hernia et al.,[13] Navin [33] stated where approximately 39.87%of patients experienced pain associated with teeth and mouth, 40.51%felt uncomfortable to eat, whereas 37.97% had unsatisfactory diet that interrupted their meals (physical disability). Psychological status of the patients was also affected as 40.51% were conscious or tensed. Coincidently, physical pain and disability was found to be the dimension of OHIP that contributed most to variation in the sex category distribution of subjects.[14],[32],[33]

In our survey of 3 months, functional limitation, physicalpain, psychosocial disability was seen more in 1 >months and 1--3months. Malesreported poor quality of life in 1--3months with higher prevalence of Grade 3 intolerable mucositis, functional limitation, and physical pain than females. Chemotherapy and its combination showed greater effect than other therapies, that is, radiotherapy, surgery alone on the QoL in <1 month and 1--3 months.[34],[35] Similar to our findings, Curran et al.[36]found poor QoL in H and Ncancer patients after treatment with high dose RTalone or in combination with cetumixab.

   Conclusion Top

The study indicated that OHIP-14 questionnaire is a reliable and valid tool in differentiating group of patients with varying functional limitations from healthyindividuals. Findings of the relevant variables showed more impact of chemotherapy and its combination therapy on the QoLof H and N cancer patients. Sex-based differences elicited higher incidence of functional and physical disability in males thanfemales. Therefore, for optimal well-being and better care of cancer patient, assessment of QoL should be considered as a part of the treatment protocol.

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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]

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