|Ahead of print
Evaluation of quality of life in patients surgically treated for potentially malignant oral lesions
Neharika Kapur1, Nishu Singla2, Adarsh Kudva3, Evit Rajan John3
1 Departments of Orthodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India
2 Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
3 Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
|Date of Submission||25-Apr-2019|
|Date of Decision||01-Jan-2020|
|Date of Acceptance||06-Jul-2020|
|Date of Web Publication||10-Dec-2020|
Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The oral potentially malignant disorders (OPMDs) can impair the quality of life (QOL) of an individual. The evaluation of various aspects of life getting affected will help the health service providers to better comprehend the problems faced by the patients. This study aimed to evaluate the postoperative QOL of surgically treated patients for OPMDs.
Materials and Methods: It was a cross-sectional study done on 45 follow-up patients, aged 24–80 years, who were surgically treated for OPMDs. A performa with questions regarding sociodemographics, personal, and abusive habits and a questionnaire on QOL was used. Oral examination was done to analyze the oral mucosa for recurrence. Data were analyzed using frequency analysis and unpaired student's t-test to compare the mean scores.
Results: Several patients reported to have experienced a lot of pain (15, 33%), burning sensation on having spicy food (36, 80%), great difficulty in opening mouth (15, 33%), alteration in taste sensation (36, 80%), limiting of eating desired food (24, 53%), and dryness of mouth (7, 16%). Many patients felt very frustrated, depressed (9, 20%), and reported their condition to have affected their satisfaction with life (19, 42%). However, neither did social relationship with family and friends got affected by this nor did it add discomfort to them at parties, social functions, or get together. Their main concern was the likelihood of their oral condition progressing into cancer. There was a statistically significant difference in the QOL scores for habit of areca nut chewing (P = 0.05), erythroplakia lesions (P = 0.05), and recurrence of lesion (P = 0.02).
Conclusion: OPMDs affected the physical, functional, and psychological well-being of study patients, caused discomfort, and affected their daily activities. However, the social well-being of patients was unaltered and a large number of patients were reportedly satisfied with their treatments. The timely diagnosis and management can improve the quality of life and prevent its progression to malignancy.
Keywords: Postsurgical management, potentially malignant oral lesions, quality of life
Key Message Oral potentially malignant disorders certainly reduced quality of life by affecting the physical, functional and psychological well-being of the patients, caused in-convenience and affected their daily life activities. However, social wellness of the patients was unaltered and a large number of patients were reportedly satisfied with their treatments.
| » Introduction|| |
Quality of life (QOL) is “the criterion of health, comfort, and happiness experienced by an individual or group”. An estimation of health-related quality of life (HRQOL) is essentially an assessment of the QOL and its connection with health. It comprehends life satisfaction, including physical and psychological functioning along with social interactions. The satisfactoriness of the surgical treatment of the patient and resuming preoperative physical, emotional, and social functioning are the life domains that still need exploration. There is a dearth of studies based on the effect that surgical treatment of oral premalignant disorders can have upon the quality of life of an individual, thus necessitating studies that can evaluate the same.
The term “Oral potentially malignant disorders” (OPMD) was developed by the World Health Organization in 1978 by merging precancerous lesions and conditions into premalignant disorders in order to discard the bias of terminologies. It is a category of disorders of different etiologies, such as tobacco or mutation or alteration in the genetic material of oral epithelial cells that may develop the malignant potential to transform to oral cancer. Premalignant oral lesions such as leukoplakia, erythroplakia, oral lichen planus, and oral submucous fibrosis are very frequently found in the oral cavity which have the potential to develop into a malignant lesion. Globally, the prevalence of OPMD is reported to be in the range of 1% to 5%.
The OPMD can significantly impair the QOL of an individual if not treated on time and can lead to higher mortality rates. The OPMD symptoms such as pain, burning sensation, trismus, and altered taste sensation most likely can reduce the QOL of these patients.,,, However, the dysfunction and fear of malignant transformation caused by OPMD is most likely to have implications on the emotional and social wellbeing. Despite OPMDs having distinguished clinical and histological features that can be identified in the early stages, most of these lesions are unfortunately ignored as they are usually painless and may progress to advanced stages with symptoms such as large ulcerations, pain, paresthesia, and lymphadenopathy. In India, 60–80% of patients report with advanced stages of the OPMDs. The early detection and timely intervention can improve the survival and quality of life.
These disorders being relatively common, chronic, and potentially malignant when treated with surgical (scalpel/laser) and/or radiotherapy can impair normal functions like speech, swallowing, chewing, and salivation. This can also impact the patient's emotional and social wellbeing. The comparison of various aspects of life getting affected by treating premalignant oral lesions will help the health service providers to better comprehend the problems faced by the patients on a daily basis and find solutions. There are very few studies found in the existing literature which have reported the effect of premalignant oral lesions on quality of life.,,, However, this study was conducted to evaluate the postoperative quality of life of surgically treated patients for potentially malignant oral lesions.
| » Materials and Methods|| |
It was a cross-sectional study carried out among surgically treated patients for potentially malignant oral lesions. Ethical approval to carry out the study was acquired from the institutional ethics committee of the Kasturba Medical College and Kasturba Hospital, Manipal. The study was conducted from February 2018 to July 2018. The study included 45 patients on follow up who had been treated surgically for potentially malignant oral lesions in the department of Oral and Maxillofacial Surgery (OMFS), Manipal College of Dental Sciences, Manipal. The patients were told about the objective and procedure of the study and informed consent was sought for questionnaire completion and clinical examination of the oral cavity. Further, the inclusion criterions for participation of the patients in the study were willingness to participate and ability to comprehend the questionnaire. They were given instructions prior to the administration of the questionnaire, and queries were solved by the investigators. Care was taken to ensure that all the questions were answered and participants were requested to complete unanswered questions, if any.
Data collection consisted of questions regarding sociodemographics which included the participants' age, gender, occupation, income, education, location, and marital status; personal habits such as device used for oral hygiene, frequency of cleaning per day, and other oral hygiene aids like mouthwash or dental floss; abusive habits such as smoking, alcohol consumption, tobacco chewing, and areca nut chewing along with a set of questions to evaluate the QOL and a format for recording clinical data. The permission to use previously validated questionnaire to evaluate the QOL of patients with OPMDs was obtained from the authors. It evaluates the personal insights of the patients on the influence of these disorders on their daily aspects of life. It consisted of 20 questions measuring four domains pertaining to their life and activities posttreatment such as difficulty with diagnosis, physical impairment and functional limitations, psychological and social well-being, and handling of effect on daily lives. The response of each question was scored on a five-point Likert scale. A higher score denotes poor QOL. The questionnaire was translated into Kannada which is the regional language of Karnataka. A back translation method including blind retranslation into English was adopted to check the validity of the same. Verification of the validity of translation was done by experts in both languages. Moreover, this was checked even after phraseology alteration to ascertain the functional and conceptual equivalence of the questionnaire.
A schedule was prepared for data collection based on an average time of 10–15 minutes for questionnaire completion and clinical examination per individual. A thorough oral examination was done to analyze the oral mucosa for recurrence, healing, and extent of the lesion. The following details of the lesions were recorded such as the type of the lesion (clinically/histologically), site of the lesion on tongue/buccal mucosa, number of lesions, size of the lesion, duration of the lesion before surgery, treatment of the lesion was wide excision with/without reconstruction or localized excision/excisional biopsy with conservative, and if any reoccurrence of the lesion. They were additionally examined for any dental treatment and were given referral cards that entitled them free treatment for the same. The clinical examination was carried out by the assessor following “Universal Precautions.” The Statistical Package for Social Sciences version 20.0 (SPSS Inc., Chicago, IL, USA) was used to analyze the data. Descriptive analyses were performed to calculate the frequencies of the answers given by study participants. The means of QOL score were compared using the unpaired t test for independent groups. The cut off level for statistical significance was taken at 0.05.
| » Results|| |
The study sample of 45 postsurgically treated OPMD patients consisted of nine women (20%) and 36 men (80%) of 24–80 years with a mean age of 53 ± 14 years. Majority of the patients (39, 87%) were from rural places with nearly, 27 (60%) belonging to the labor class having an income of <5000 rupees per month (30, 67%). Most of the patients (32, 71%) had only primary secondary education and very few had higher education (13, 29%). All were married except one patient. Also, there was no statistically significant difference of QOL of postsurgically treated OPMD patients based on their demographic parameters [Table 1]. However, 18 (40%) of the patients agreed that their oral condition had affected their income and occupation. Most patients (32, 71%) used toothbrush to clean their teeth and brushed twice daily (31, 69%). Majority of the patients did not use any other oral hygiene aid except a few (6, 13%) those reported to have used a mouthwash. The habit of areca nut chewing was reported by majority of the patients (31, 69%) followed by tobacco (gutka) chewing (16, 36%), alcohol consumption (12, 27%), and smoking cigarette/beedi (9, 20%). Out of all the oral abusive habits of the patients, areca nut chewing was found to have a statistically significant difference in the QOL scores of postsurgically treated OPMD patients (P value = 0.05). Patients who had reported to chew areca nut had significantly poorer quality of life than those without the habit [Table 2].
|Table 1: Quality of Life (QOL) based upon the demographics of the study participants|
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|Table 2: Quality of life (QOL) based upon the oral habits and personal behavior of the patients|
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The difficulty faced by OPMD patients while diagnosis was assessed using a questionnaire; it was found that most of the patients (39, 87%) had only a little/slight difficulty in getting their mouth condition diagnosed. Due to visiting many doctors for their diagnosis, many patients agreed that it had affected their daily life activities to some extent (29, 64%) while some of them were greatly affected (8, 18%). Most of the patients were stressed to some extent while taking a variety of treatments before their diagnosis but 8 (18%) were reported to have been in very much/quite a bit stress. Likewise, the physical impairment and functional limitations of the patients was assessed, it was found that lot of patients (15, 33%) experienced quite a bit/very much pain and agony due to their mouth condition. Except for 9 (20%), all other patients have reported having little to very much burning sensation on having spicy food. Nearly 15 (33%) of the patients found it greatly difficult to open their mouth widely. Many of the patients reported alteration in taste sensation (13, 29%) quite a bit/very much and 23 (50%) somewhat/little, limiting of eating desired food (14 (31%) quite a bit/very much and 10 (22.2%) somewhat), and dryness of mouth (7 (16%) quite a bit/very much) [Table 3].
|Table 3: Quality of life in surgically treated oral premalignant disorder patients|
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Furthermore, the psychological and social well-being was assessed and showed that half of the patients were quite/very scared about the likelihood of their oral condition turning into cancer. Nearly 9 (20%) of the patients felt very frustrated and depressed and 19 (42%) reported their condition had affected their satisfaction with life. Almost half of the patients were certain that their mouth condition did not affect or had minimal effect on their relationship with family, friends. A large number of patients (27, 60%) reported being not at all or not much embarrassed while eating food at parties, functions, or other social gatherings. In addition, the effect of treatment on daily lives was explored and it was found that a large number of patients (30, 67%) were reportedly satisfied with their treatment. However, 33 (73%) of the patients stated that their treatment appointments had affected their daily lives. Nearly 9 (20%) of patients reported to have experienced a lot of pain after the treatment of their condition [Table 3].
In the present study, 30 (66.7%) patients had leukoplakia, 11 (24.4%) had erythroplakia, and 4 (8.9%) had oral lichen planus. It was found that patients with erythroplakia had statistically significant inferior quality of life as compared to patients with leukoplakia (p value = 0.05). Histological examination revealed 18 (40%) of the lesions had mild dysplasia, 16 (35.6%) had moderate dysplasia, and 11 (24.4%) patients had severe dysplasia. Majority of the patients had one premalignant lesion (35, 78%) with the mucosa being the common site of occurrence (32, 71%) as compared to tongue (13, 29%). The size of the lesion was ≤ 2.25 cm2 in almost half of the patients. The duration of the lesion from the date of diagnosis up to the surgery was reported less than one year in 25 (56%) of the patients. Surgical/laser excision with reconstruction treatment was needed for 27 (60%) of patients and localized excision/excisional biopsy with conservative treatment for 18 (40%) of patients. But, none of these parameters were found to have any statistically significant difference in the QOL of the patients. The reoccurrence of the lesion was found in 16 (36%) of the patients and was found to have a statistically significant inferior quality of life as compared to nonreoccurrence counterparts (p value = 0.02) [Table 4].
|Table 4: Quality of life (QOL) based upon the lesion characteristics of the patients|
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| » Discussion|| |
QOL is considered a vital health outcome measure that is relevant to patient care. The present study was conducted in order to evaluate the QOL in patients surgically treated for potentially malignant oral lesions. This study was mainly designed to comprehend the difficulties faced by OPMD patients while diagnosis to know about the level of physical impairment and functional limitations of them, to check the influence on their psychological and social well-being and to see the effect of treatment on their daily lives. According to the present study, most of the patients had to undergo some difficulty during the diagnosis of the condition due to visiting many doctors and taking a variety of treatments. OPMDs had certainly affected their physical and functional dimensions of life as a lot of patients reported to have experienced very much pain and agony due to their mouth condition such as experiencing burning sensation on having spicy food, difficulty to open their mouth widely, alteration in taste sensation, limitation of eating desired food, and dryness of mouth. These findings were similar to those reported by other studies done earlier.,,,
It was found that OPMD had also affected the psychological well-being of the patients as many patients felt very frustrated and depressed and reported their condition to have affected their satisfaction with life. Their main concern was about the possibility of their oral condition turning into cancer. However, social relationship with family and friends were not affected and it did not discomfort them at parties, functions, or other social gatherings. This may be mainly because of timely diagnosis, early intervention, and more conservative treatment that have led to largely unaltered quality of life in these patients as an advantage as compared to patients with oral cancer. In the present study, a large number of patients were reportedly satisfied with their treatment. However, many patients agreed their treatment appointments had affected their daily lives.
Areca nut chewing is typically known for causing oral submucous fibrosis and reduces QOL. It was found to have a significant detrimental effect on the QOL of the patients in the present study. Areca nut chewing is an integral part of these patients' culture and lifestyle; hence, it is extremely crucial for the health care workers to make them aware of the deleterious consequences of the same and other oral abusive habits. The presence of other habits such as tobacco chewing, smoking, or alcohol abuse habits in patients did not significantly defer the quality of lives of these patients., The statistical insignificance in the present study might be due to real insignificant altered QOL in these OPMD patients or could also have been as a result of the less sample size of treated patients with such habits included in the study. This need to be further confirmed with larger sample size research by including patients having more of these habits. Still, there is an imperative need to spread awareness among people about oral abusive habit cessation, reporting any symptoms at an early stage, and also promptly availing treatment so as to maintain their quality of life.
Furthermore, it was found that patients those had erythroplakia and reoccurrence of second primary lesions in their oral cavity had significantly lower QOL. This may be because of the more aggressive nature of the lesions with comparatively severe symptoms. This may also be due to the more inconvenience faced by the patients during rediagnosis and retreatment. This can be prevented with early diagnosis with advanced diagnostic instruments and better quality of treatment. Patient satisfaction is the an important parameter to judge the quality of health care service provided and a large number of study patients were reportedly satisfied with their treatments. Hence, more vigilance and carefulness needs to be maintained to improve the quality of life and prevent its progression to malignancy in the future.
| » Conclusion|| |
OPMDs affected the physical, functional, and psychological well-being of the study patients, caused inconvenience, and affected their daily life activities. However, social wellness of patients was unaltered and a large number of patients were reportedly satisfied with their treatments. The timely diagnosis and management can improve the quality of life and prevent its progression to malignancy in the future. Hence, it is essential to make people aware about oral abusive habit cessation, self-oral examination, regular oral health checkups, and screening and treatment for better quality of life.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]