Extraoral Maxillofacial Prosthetic Materials: Results of the 2020 International Survey.

PURPOSE: To report the results of a 2020 international survey of the most commonly used materials and techniques for the fabrication of extraoral maxillofacial prosthetics, and to assess the use of 3D technology. MATERIALS AND METHODS: A 43-question survey was administered via Qualtrics to the members of the American Academy of Maxillofacial Prosthetics (AAMP), the International Anaplastology Association (IAA), and the International Society of Maxillofacial Rehabilitation (ISMR). The use of current 3D technology in the fabrication of maxillofacial prostheses as well as barriers to care such as patient cost and insurance coverage were also assessed. RESULTS: In total, 134 respondents (13%) completed the survey; 96 (73%) reported that they were currently fabricating maxillofacial prostheses and were thus included in the survey. The majority of respondents reported currently using Silastic MDX4-4210 BioMedical Grade Elastomer (DuPont) with either Silastic Medical Adhesive Silicone Type A or Silastic MDX4-4210 crosslinker. Incorporating the use of current CAD/CAM technology was reported by a majority of respondents (58%; 45/77); however, a small cohort (33%, 15/45) reported they were still experimenting how best to use technology. A total of 39 clinicians (49%) reported that facial prosthetics were most often paid for by the patient (fee for service), with the fees ranging from $10 to $5,500 USD. CONCLUSIONS: The results of this survey indicate that current CAD/CAM technology has been adopted and incorporated into the design and fabrication of maxillofacial prostheses. More research is needed to advance CAD/CAM technology as well as the physical and mechanical properties of materials in maxillofacial prosthetics and anaplastology clinical practice. Int J Prosthodont 2023;36:570-580.

Manual Therapy for Patients With Radiation-Associated Trismus After Head and Neck Cancer.

Importance: Trismus is highly prevalent in head and neck cancer (HNC) survivorship. Current standards for trismus treatment include various stretch-based exercise protocols as a primary and single treatment modality with limited evidence regarding the role of manual therapy (MT) for this indication. Objective: To assess the effect size and associations of response to MT to increase oral opening in the setting of radiation-associated trismus. Design, Setting, and Participants: This retrospective case series was conducted at the University of Texas MD Anderson Cancer Center between 2016 and March 2020 (before COVID-19 interruption) and included 49 disease-free survivors of HNC who were referred for treatment of radiation-associated trismus. Intervention: Intraoral MT (including or excluding external head and neck) targeting the muscles of mastication. Main Outcomes and Measures: Maximum interincisal opening (MIO) before and after the initial MT session compared with serial MT sessions. Covariates were examined to determine the association with response to MT for trismus. Results: A total of 49 survivors of HNC (13 women [27%]; 24 [49%] 64 years or younger; 25 [51%] 65 years or older; mean [range] of 6.6 [0-33] years postradiotherapy were included, 9 [18.4%] of whom underwent a single MT session; 40 [81.6%] who underwent multiple sessions [mean, 6; median (range), 3 (2-48)]). The MIO improved after a single session by a mean (SD) of 4.1 (1.9) mm (0.45 effect size) and after serial MT sessions by a mean (SD) of 6.4 (4.8) mm with an effect size of 0.7. No covariates were found to be clinically meaningfully associated with MIO improvement following MT. Conclusions and Relevance: The findings of this case series study suggest that MT improved MIO with a medium to large effect size in survivors of HNC with radiation-associated trismus. The results suggest that the largest increase in oral opening was achieved after the initial treatment and although gains were more modest, oral opening continued to improve with serial treatment. Covariates were not associated with MT response, suggesting that patients with clinical features often considered treatment refractory (eg, advanced disease, multiple lines of oncology treatment, ≥5 years posttreatment) may benefit from treatment with MT. Manual therapy may be a beneficial frontline or adjuvant treatment when combined with traditional stretching therapy. A clinically meaningful increase in oral opening has the potential to improve swallow function, speech, pain, and quality of life.

Reconstruction of intraoral oncologic surgical defects with Integra® bilayer wound matrix.

Utilization of biologic skin substitutes for the management of soft tissue defects as an alternative to autologous skin grafts has expanded over the past 2 decades. The purpose of this case series study was to report our experience with Integra® bilayer wound matrix for reconstruction of intraoral oncologic defects. Case records of 6 patients with intraoral oncologic defects reconstructed with Integra® bilayer wound matrix were retrospectively reviewed. The surgical defect location, size, and time to removal of surgical splint varied. Clinically, normal oral epithelialization was noted for all patients. One patient demonstrated a small area of dehiscence and bone exposure after adjuvant radiation therapy which resolved with minimal intervention. Integra bilayer wound matrix is a viable and versatile option for reconstruction of intraoral oncologic surgical defects. Further exploration of wound healing with Integra® matrix, surgical techniques, and cost-effectiveness is advocated.

Self-Reported Trismus: prevalence, severity and impact on quality of life in oropharyngeal cancer survivorship: a cross-sectional survey report from a comprehensive cancer center.

OBJECTIVE: The purpose of this study was to estimate prevalence/severity of self-reported trismus, determine association with quality of life (QOL), and examine clinical risk factors in a large population of patients treated for oropharyngeal cancer. MATERIALS AND METHODS: A cross-sectional survivorship survey was conducted among patients who completed definitive treatment for oropharyngeal carcinoma, disease-free ≥ 1-year post-treatment (median survival, 7 years among 892 survivors). Associations between trismus and QOL were also analyzed using MDASI-HN, EQ-5D, and MDADI. Dietary and feeding tube status were also correlated to trismus status. RESULTS: Trismus was self-reported in 31%. Severity of trismus positively correlated (r = 0.29) with higher mean interference scores reflecting a moderate association with quality of life (p < 0.0001). There was a negative correlation for MDADI composite scores (r = - 0.33) indicating increased perceived dysphagia related to trismus severity (p < 0.0001). EQ-5D VAS scores were also negatively correlated with trismus severity (r = - 0.26, p < 0.0001). Larger T-stage (p ≤ 0.001), larger nodal stage (p = 0.03), tumor sub-site (p = 0.05), and concurrent chemoradiation (p = 0.01) associated with increased prevalence of trismus. Diet negatively correlated (r = - 0.27) with trismus severity (p = < 0.0001), and survivors with severe trismus were also more likely to be feeding tube-dependent. CONCLUSION: Severity of trismus appears to negatively impact quality of life and associate with various adverse functional outcomes in long-term oropharyngeal cancer survivorship. Trismus remains associated with advanced disease stages, tumor sub-site (tonsil), and addition of chemotherapy. Further investigation is merited for the dose-effect relationship to the muscles of mastication.

Hypomagnesemia and incidence of osteoradionecrosis in patients with head and neck cancers.

BACKGROUND: We aimed to determine whether hypomagnesemia predicts osteoradionecrosis development in patients with squamous cell carcinoma of the oropharynx and oral cavity who received platinum-based concurrent chemoradiation with or without induction therapy. METHODS: We reviewed data from patients with head and neck cancers who had undergone chemoradiation with weekly cisplatin/carboplatin between January 1, 2010 and December 31, 2014 at our institution. Pathologic features, laboratory test results, disease stage, and social histories were recorded. The association between hypomagnesemia and osteoradionecrosis was analyzed controlling for known confounding factors. RESULTS: Hypomagnesemia during cancer treatment was associated with osteoradionecrosis development (HR = 2.72, P = .037) independent of total radiation dose (HR = 1.07, P = .260) and smoking history (HR = 2.05, P = .056) among the patients who received platinum-based induction chemotherapy followed by concurrent chemoradiation. CONCLUSIONS: Hypomagnesemia was predictive of the development of osteoradionecrosis in patients with cancers of the oropharynx and oral cavity receiving platinum-based induction followed by concurrent chemoradiation.

A Dosimetric Comparison of Oral Cavity Sparing in the Unilateral Treatment of Early Stage Tonsil Cancer: IMRT, IMPT, and Tongue-Deviating Oral Stents.

INTRODUCTION: Tongue-deviating oral stents (TDOS) are commonly used during unilateral neck radiation therapy to reduce unnecessary dose to nontarget oral structures. Their benefit in the setting of highly conformal treatment techniques, however, is not defined. The goal of this study was to investigate the potential benefit of TDOS use on dosimetric parameters in unilateral intensity modulated radiation therapy (IMRT) and intensity modulated proton therapy (IMPT). METHODS: A total of 16 patients with T1-2 tonsil cancer treated at a single institution were selected, of which 8 were simulated/treated with a TDOS and 8 without a TDOS. All received definitive unilateral IMRT to a dose of 66 Gy in 30 fx. IMPT plans were generated for each patient for study purposes and optimized according to standard institutional practice. RESULTS: For IMRT plans, the presence of a TDOS (vs without) was associated with a significantly lower oral mucosa mean dose (31.4 vs 35.3 Gy; P = .020) and V30 (42.7% vs 57.1%; P = .025). For IMPT plans, the presence of TDOS (vs without) was not associated with any improvement in oral mucosa mean dose (18.3 vs 19.9 Gy; P = .274) or V30 (25.0% vs 26.2%; P = .655). IMPT plans without TDOS compared with IMRT plans with TDOS demonstrated reduced oral mucosa mean dose (P < .001) and V30 (P < .001). CONCLUSION: The use of a TDOS for the unilateral treatment of well-lateralized tonsil cancers was associated with oral mucosa sparing for IMRT, but not for IMPT. Moreover, mucosa sparing was improved for IMPT plans without a TDOS compared to IMRT plans with a TDOS.

The impact of tongue-deviating and tongue-depressing oral stents on long-term radiation-associated symptoms in oropharyngeal cancer survivors.

OBJECTIVES: To evaluate whether the use of oral stents during intensity modulated radiation therapy (IMRT) for oropharyngeal cancer (OPC) is associated with long-term patient reported symptoms. MATERIALS AND METHODS: Data was obtained from a prospective observational study of disease-free head and neck cancer survivors. Radiation-associated patient reported symptoms were assessed using the MD Anderson Symptom Inventory Head and Neck module (MDASI-HN). Scores of ≥5 (11-point Likert scale, 0-10) were considered moderate/severe. Stratification was performed regarding IMRT volume (uni- versus bilateral neck) and stent utilization, with non-parametric analyses between groups. RESULTS: 462 OPC survivors formed the cohort (54% tonsil, 46% base of tongue primaries). A tongue-deviating stent was used in 17%, tongue-depressing stent in 46%, and no stent in 37%. Median prescribed dose to the high dose clinical target volume was 66.0 Gy. Median follow-up from RT to MDASI-HN assessment was 68 months. Twenty percent had received unilateral neck RT (all had tonsil primaries), in whom a significant improvement in the proportion of patients with moderate/severe taste impairment (2% vs. 15%, p = 0.047) and lack of appetite (0% vs. 9%, p = 0.019) was associated with the use of tongue-deviating stents compared to no oral stent. In those who had received bilateral neck RT, a significant improvement in the proportion of patients with moderate/severe difficulty swallowing/chewing was associated with use of a tongue-depressing stent (21% vs. 31% without oral stent, p = 0.013). CONCLUSION: Disease-site specific select use of oral stents during IMRT was associated with reduced long-term patient reported symptoms in OPC survivors.

Prospective observational evaluation of radiation-induced late taste impairment kinetics in oropharyngeal cancer patients: Potential for improvement over time?

BACKGROUND AND PURPOSE: Taste impairment is a common radiation-induced toxicity in head and neck cancer (HNC) patients acutely. However, data on the potential for recovery and the time dependent course of late taste impairment are limited. MATERIALS AND METHODS: As part of an IRB-approved observational prospective study, HNC patients underwent serial surveys including the MD Anderson Symptom Inventory - Head and Neck module (MDASI-HN). For our analysis, we extracted MDASI-HN taste item results from oropharyngeal cancer patients treated with intensity-modulated radiotherapy or volumetric modulated arc therapy and at least two taste assessments after ≥1 year from end of radiotherapy (RT). RESULTS: 1214 MDASI taste items from 326 patients between 1 and 13 years post-RT were included. Median prescribed dose to the high-dose clinical target volume (CTV1) was 66.0 Gy, with 180 patients (55%) receiving chemotherapy. Taste markedly improved in the first years from end of RT, but plateaued after year 5. In patients with taste assessment in subsequent years, a significant reduction in taste impairment was found from the second to the third year (p = 0.001) and tended towards significance from the third to the fourth year (p = 0.058). Multivariate analysis revealed treatment site as significant factor in the sixth year from RT and CTV1 dose and age in the seventh year. CONCLUSION: Radiation-induced taste impairment may improve over an extended time interval, but becomes relatively stable from year 5 post-RT. Direct characterization of RT-induced taste impairment and the calculation of normal tissue complication probability should include consideration of the time-dependent course in taste recovery.

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic.

BACKGROUND: COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel. METHODS: The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular. RECOMMENDATIONS: Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred. CONCLUSION: These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

An alternative impression technique for capturing anatomic undercuts to rehabilitate a patient with a total maxillectomy: A clinical report.

Patients who have undergone a bilateral maxillectomy are particularly difficult to rehabilitate prosthetically by using a conventional obturator prosthesis, mainly because of the extensive loss of tissues for retention and support. In these situations, adapting to existing undercuts within the defect is essential. Traditional impression techniques capture certain anatomic landmarks but may fall short of the needed sinus undercuts. This article describes an alternative impression technique for capturing 3 opposing undercuts to help retain, support, and stabilize a hollow 1-piece obturator prosthesis for a patient who underwent a total maxillectomy.

Patient reported dry mouth: Instrument comparison and model performance for correlation with quality of life in head and neck cancer survivors.

PURPOSE: To identify a clinically meaningful cut-point for the single item dry mouth question of the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). METHODS: Head and neck cancer survivors who had received radiation therapy (RT) completed the MDASI-HN, the University of Michigan Hospital Xerostomia Questionnaire (XQ), and the health visual analog scale (VAS) of the EuroQol Five Dimension Questionnaire (EQ-5D). The Bayesian information criteria (BIC) were used to test the prediction power of each tool for EQ-5D VAS. The modified Breiman recursive partitioning analysis (RPA) was used to identify a cut point of the MDASI-HN dry mouth score (MDASI-HN-DM) with EQ-5D VAS, using a ROC-based approach; regression analysis was used to confirm the threshold effect size. RESULTS: Two-hundred seven respondents formed the cohort. Median follow-up from the end of RT to questionnaire completion was 88 months. The single item MDASI-HN-DM score showed a linear relationship with the XQ composite score (ρ = 0.80, p < 0.001). The MDASI-HN-DM displayed improved model performance for association with EQ-5D VAS as compared to XQ (BIC of 1803.7 vs. 2016.9, respectively). RPA showed that an MDASI-HN-DM score of ≥6 correlated with EQ-5D VAS decline (LogWorth 5.5). CONCLUSION: The single item MDASI-HN-DM correlated with the multi-item XQ and performed favorably in the prediction of QOL. A MDASI-HN-DM cut point of ≥6 correlated with decline in QOL.

The multiple oral presentations of multiple myeloma.

PURPOSE: The purpose of this case series is to show the varied oral presentations of multiple myeloma, illustrating the importance of carefully surveying the oral cavity for suspicious lesions that could be indicative of palpable disease and/or recurrence. The diagnostic criteria and prognostic features for multiple myeloma were also reviewed. CASE SERIES SUMMARY: This report focuses on five patients with myeloma manifestations involving the oral cavity, in which the oral presentation of multiple myeloma was an early indication of disease relapse. Although the clinical presentation may be variable, the majority of patients will develop lytic bone lesions and less commonly, extramedullary involvement during the course of their disease. DISCUSSION: The presentation of myeloma can be varied and the oral presentation, although rare, may be the sole manifestation or part of a group of signs of disease progression. Clinical presentations of patients with myelomatous lesions can mimic common dental pathologies, which then, in turn, can lead to delays in diagnosis and treatment. CONCLUSION: As members of an interdisciplinary oncology team, it is essential to be familiar with oral manifestations of multiple myeloma and proper diagnostic/biopsy techniques in order to avoid misdiagnosis and treatment delays.

Survey of currently selected dental implants and restorations by prosthodontists.

PURPOSE: The purpose of this study was to survey the prosthodontists of the American College of Prosthodontists (ACP) and the American Academy of Maxillofacial Prosthetics (AAMP) to identify the most commonly used implant both during their training and currently in practice, and to evaluate overall restorative preference. Participants were asked to rank criteria that make an implant company desirable and important features when selecting an implant. MATERIALS AND METHODS: An electronic survey was emailed to 1,739 members of the ACP and AAMP. RESULTS: The majority of respondents (79%) were trained using Nobel Biocare brand implants, which was also the brand most often selected by participants for use in all regions of the oral cavity (34% to 39%, location dependent). Abutment preferences varied by area: incisors and canines (29%) and highly esthetic areas (53%) were more likely to be restored with custom milled zirconia abutments, while prefabricated titanium abutments were preferred for premolars and molar areas. Conventional loading was most often applied, ranging from 95% in medically compromised patients to 55% in esthetic areas. The majority of participants (86%) used Locator attachments for complete overdenture restorations. Also, respondents selected an implant company based on features and literature support versus cost and customer service. The implant features deemed most important were the design of the internal connection and ease of finding replacement parts; thread design and variety of abutments were deemed least important. Respondents reported that while implant planning software was used, they rarely/never order the concurrent surgical guide. CONCLUSION: Within the study's limitations, the majority of prosthodontists select implants based on training, features, and literature support.

Adesão dos pacientes ao tratamento para osteoporose em Tubarão- SC / Adhesion of patients to osteoporosis treatment in Tubarão- SC

Objetivo - Conhecer a adesão de pacientes diagnosticadoscom osteoporose, que fizeram exame de densitometriaóssea em uma clínica de ortopedia e imagemde Tubarão- SC, ao tratamento proposto. Métodos - Estudotransversal realizado por meio de questionário etestes de adesão medicamentosa validados no Brasil,aplicados em 93 pacientes, com idade superior a 50anos, com osteoporose que fizeram exame de densitometriaóssea na clínica Ortoimagem em Tubarão-SCno período de Janeiro de 2008 a Dezembro de 2010,incluídos na pesquisa, após consentimento informado.Resultados ? dos 93 pacientes que fizeram parte do estudo,houve predominância do sexo feminino, 97,85%.A média de idade foi de 68,23 anos. Utilizando o testede adesão medicamentosa de Morisky-Green-Levine,verificou-se que 53,8% não aderem ao tratamento paraosteoporose. Dentre os motivos que levam os pacientesa não aderirem o tratamento proposto, 46,2% dosentrevistados se esquecem de tomar os medicamentos,40,9% são descuidados com a hora de tomar a medicação,21,5% param de tomar a medicação quando sesentem bem e 33,3% param de tomar quando se sentemmal. Apenas 12,9% dos pacientes colocaram corrimãoem banheiro após o diagnostico. Conclusão: concluiu-se que 53,8% dos entrevistados não aderem aotratamento, e que o principal motivo é o esquecimentode tomar suas medicações.

Objective-To know the adherence of patientsdiagnosed with osteoporosis who underwent a bonedensitometry on an orthopedics and image clinic ofTubarão-SC for the proposed treatment. Methods -Cross-sectional study using a questionnaire and drugadhesion tests validated in Brazil, applied in 93 patients,aged above 50 years, with osteoporosis whounderwent a bone densitometry on Clínica Ortoimagemin Tubarão- SC in the period of January 2008 toDecember 2010, included in the study after informedconsent. Results - From the 93 patients who participatedin the study there was a female dominance,97.85%. The average age was 68.23 years. Using thedrug adhesion test of Morisky-Green-Levine, it wasfound that 46.2% of respondents adhere to treatmentand 53.8% didn?t adhere to treatment for osteoporosis.Among the reasons to why patients donot adhere to the proposed treatment, 46.2% respondentsforget to take the medication, 40.9% arecareless with the time to take the medication, 21.5%stopped taking the medication when they felt goodand 33.3% stopped taking it when they felt bad.Conclusion: it was found that 53.8% didn?t adhereto treatment, and that the main reason is that 46.2%forget to take their medications.