A modified triangular flap suture method used for inferior third molar extraction: A three-arm randomized clinical trial for the assessment of quality of life.

BACKGROUND: The purpose of this study is to explore whether decreasing the number of sutures can improve the quality of life after inferior third molar extraction. MATERIAL AND METHODS: This study used a three-arm randomized design that included 90 individuals. Patients were randomized and divided into three groups-the airtight suture group (traditional), the buccal drainage group, and the no-suture group. Postoperative measurements, including treatment time, visual analog scale, questionnaire on postoperative patient quality of life, and details about trismus, swelling, dry socket, and other postoperative complications were obtained twice and the mean values were recorded. To verify the normal distribution of the data, the Shapiro-Wilk test was performed. The statistical differences were evaluated using the one-way ANOVA and the Kruskal-Wallis test with Bonferroni post-hoc correction. RESULTS: The buccal drainage group showed a significant decrease in postoperative pain and better speech ability than the no-suture group on the 3st day, with a mean of 1.3 and 0.7 (P < 0.05). The airtight suture group also showed similar eating and speech ability, which was better than the no-suture group, with a mean of 0.6 and 0.7 (P < 0.05). However, no significant improvements were noted on the 1st and 7th days. The surgical treatment time, postoperative social isolation, sleep impairment, physical appearance, trismus, and swelling showed no statistical difference between the three groups at all measured times (P > 0.05). CONCLUSIONS: Based on the above findings, the triangular flap without a buccal suture may be superior to the traditional group and no-suture group in less pain, and better postoperative patient satisfaction in the first 3 days and may be a simple and viable option in clinical practice.

Assessment and management of radiation-induced trismus in patients with nasopharyngeal carcinoma: a best practice implementation project.

INTRODUCTION AND AIMS: Intensity-modulated radiotherapy (IMRT) is the most commonly used radiotherapy technology in oncology, which enables precise conformation of the radiation dose to the target volume and reduces the risk of radiation damage to the adjacent normal structures. Nevertheless, it is still inevitable for IMRT of head and neck cancer to cause radiation-related toxic and side effects, such as dry mouth, mucositis, oral dysarthria, taste disorder, osteonecrosis, and trismus. Trismus is one of the most common late side effects caused by radiotherapy of nasopharyngeal carcinoma (NPC), which seriously affects the quality of life for patients with NPC. However, the current clinical assessment and management of trismus after radiotherapy for NPC are still imperfect. This best practice implementation project aimed to implement an evidence-based practice in assessing and managing trismus for NPC patients who underwent radiotherapy, thereby improving the compliance of clinical practice with the best evidence and the quality of life of patients with NPC. METHODS: This evidence-based audit and feedback project was implemented using a three-phase approach at a third-class hospital in China, following JBI's Practical Application of Clinical Evidence System (PACES) and GRiP evidence application. The first phase included a baseline audit with six evidence-based audit criteria derived from the best available evidence. The second phase included analyzing the results of the baseline audit, identifying barriers to compliance with best practice principles, and developing and implementing strategies to address the barriers identified in the baseline audit. The third phase involved a follow-up audit to assess the results of the interventions implemented to improve practice. RESULTS: After evidence application, the compliance rate for audit criterion 1 increased from 0% at baseline audit to 70% at follow-up audit. The compliance rate for audit criterion 2 increased from 0% to 100%. The compliance rate for audit criterion 3 increased from 22 to 62%. The compliance rate for audit criterion 4 increased from 88 to 100%. The compliance rate for audit criterion 5 was 100% at baseline audit and follow-up audit. The compliance rate for audit criterion 6 increased from 0 to 55%. CONCLUSION: Implementation of the best evidence for the assessment and management of trismus of patients with NPC after radiotherapy is conducive to improving the compliance of clinical practice with the best evidence, standardizing clinical nursing practice, improving the quality of clinical nursing, and better preventing severe trismus in patients with NPC after radiotherapy.

Randomised feasibility study to compare the use of Therabite® with wooden spatulas to relieve and prevent trismus in patients with cancer of the head and neck.

Our aim was to compare the efficacy of the Therabite® jaw motion rehabilitation system (Atos Medical) with that of wooden spatulas to relieve and prevent trismus in patients who have had radiotherapy for stage three and four oral and oropharyngeal cancer. Secondary aims were to assess the feasibility and the impact of exercise on health-related quality of life (QoL), and the use of health services after treatment. We designed a randomised, open-label, controlled, three-centre feasibility study to compare the effectiveness and cost of the Therabite® and wooden spatulas. We studied compliance with exercises and health-related QoL, assessed cost using three health economics measures, and conducted semistructured interviews with patients. Patients were randomised into two groups: the Therabite® group (n=37) and the wooden spatula group (n=34). All patients had some sense of jaw tightening before the study started. Mean mouth opening after six months increased in both groups, but the difference between the groups was not significant (p=0.39). Completion rates for the three economic measures were good. There was no significant difference between the two groups in frequency of contact with care services or in QoL. Exercises during and after radiotherapy can ameliorate trismus in patients with stage three and four oral and oropharygeal cancers, but differences between groups in efficacy, compliance, QoL, or use of hospital or community health services, were not significant.

Objective assessment of trismus in oral and oropharyngeal cancer patients treated with intensity-modulated radiation therapy (IMRT).

PURPOSE: The aim of this study was to estimate the prevalence of trismus in oral and oropharyngeal cancer patients (OOPC) treated with intensity-modulated radiation therapy (IMRT) and to identify the role of risk factors in patients who developed trismus. MATERIALS AND METHODS: A retrospective cohort study of OOPC treated with IMRT in our institution from 2009 to 2014 was performed. Patients eligible for this study had pre-RT and post-RT maximal inter-incisal opening (MIO) measurements at 6-48 months post-RT, treated with high-dose radiation (≥60 Gy) and pre-RT MIO ≥36 mm. A descriptive analysis to identify the incidence of trismus, with trismus stated as MIO ≤35 mm at or after 6 months post-RT measurement was performed. The role of risk factors such as age, gender, tumor site, tumor size (T), tumor stage, pre-RT MIO measurements and radiation dose to the tumor were assessed using Fisher exact test and the radiation doses to the ipsilateral muscles of mastication in patients who developed trismus were assessed by matching with control (non-trismus) patients using Wilcoxon Signed Rank test. RESULTS: The study consisted of 54 patients with a median age of 55 years and 81% were males. The median follow-up time was 10 months. The prevalence of trismus was 14.8%. Patients with pre-RT MIO measurements ≤40 mm were at risk of developing trismus (P < 0.001). In trismus patients, the average mean radiation dose to the masseter and medial pterygoid muscles was numerically higher but not significantly different (P = 0.08; P = 0.22, respectively) to matched control patients. Age, gender, radiation dose to the tumor, tumor site, size (T) and stage were also found to be not significant. CONCLUSION: Pre-RT MIO measurement was a significant risk factor for the development of trismus. However, this is a non-modifiable factor. Limiting radiation dose to the muscles of mastication could prevent this complication.

Radiation-induced temporo-mandibular joint disorder in post-radiotherapy nasopharyngeal carcinoma patients: assessment and treatment.

Nasopharyngeal carcinoma (NPC) is endemic in southern China, and its incidence in Hong Kong is relatively high. Radiotherapy is the mainstay treatment for NPC due to its relatively high radiosensitivity and deep-seated anatomical position, which is not readily accessible by surgery. Although the technique of radiotherapy in NPC has been advancing and offers promising treatment outcome, complications around the irradiation areas are inevitable and the quality of life of the post-radiotherapy patients is often compromised. Trismus, which is defined as the restricted mouth opening or jaw movement due to the disorder of temporo-mandibular joint (TMJ), is one of the possible late complications for radiotherapy of NPC and is found in 5-17% of the post-radiotherapy (post-RT) patients. Trismus at early stage may only affect the speech, but in severe cases nutritional intake and oral hygiene condition may deteriorate seriously. This article reviewed the possible causes of radiation-induced TMJ damage, the various assessments including imaging modalities and possible treatments. The conclusion is that the availability of simple, yet effective examinations for trismus is essential for delaying the progression and restoring TMJ functions. Although there is no absolutely effective treatment for trismus, many supportive, restorative and palliative management are possible under different clinical situations.

Oral complications of head and neck radiotherapy: prevalence and management.

AIM: The aim of the study was to evaluate the short-term and long-term toxicity caused by radiation treatment in the head and neck with the technique of intensity-modulated radiotherapy (IMRT). METHODS: We selected 20 patients, 18 men and 2 women aged between 21 and 71 years, undergoing radiation therapy (IMRT) in head and neck. Patients were visited during radiotherapy and followed for six months after the end of the therapy. We assessed the presence of: mucositis, xerostomia, dysgeusia, dysphagia, pain, trismus and, in the case of late-onset complications, radiation cavities. RESULTS: Acute toxicity: in 20 patients, 18 reported mucositis, 19 xerostomia, 17, dysgeusia, 15 dysphagia, 18 had pain and 3 patients had trismus. Tardive toxicity: in 14 patients, 5 reported mucositis, 11 xerostomia, 6 dysgeusia, 2 dysphagia, 3 had pain, 4 trismus and in 4 patients were found radiation cavities. CONCLUSION: Acute complications with higher prevalence were xerostomia (19 of 20 patients), dysgeusia of 2nd grade (11 patients of 20), mucositis of 1st grade and pain of 1st grade (10 patients of 20). Among the late complications it was noted a maintenance of the high prevalence of xerostomia (11 patients of 14) and an increase in prevalence of trismus (4 patients of 14) against a reduction of all other complications. The presence of radiation cavities in 4 patients of 14 was also recorded.

Reliability and validity of self-assessment of mouth opening: a validation study.

BACKGROUND: The objective of this study was to evaluate the reproducibility and validity of patients' mouth opening measurements in a research setting. METHODS: Firstly, 68 patients made repeated self-measurements of mouth opening using a cardboard scale (Therabite Range of Motion Scale - TRMS). Secondly, 80 patients enrolled in a clinical trial on morbidity after lower third molar surgery, made daily assessments during the postoperative week. Patients' measurements were then compared to gold-standard clinicians' measurements. RESULTS: Reliability of patients' measurements was excellent with an intraclass correlation coefficient of 0.92. The patient's measurements correlated well with the gold-standard clinician's measurements, both for the first 68 patients (Pearson's rho ranging from 0.86 to 0.90, p < 0.0001) as well as for the 80 patients enrolled in the clinical trial (rho = 0.82, p < 0.0001 at day 2, rho = 0.83, p < 0.0001 at final visit). CONCLUSIONS: TRMS can be used by patients to produce reproducible and valid mouth opening measurements.

Management of trismus following radiation therapy by cost-effective approach.

Radiotherapy when used in head and neck cancer treatment can produce side effects in patients such as the trismus. If allowed to progress trismus can become so severe that the patient becomes debilitated due to lack of nutrition. Furthermore, trismus and limited oral access present a challenge to the clinician for dental treatment. This article describes a simple and cost-effective appliance for management of trismus.

Developing a CTCAEs patient questionnaire for late toxicity after head and neck radiotherapy.

PURPOSE: Patient-based reporting of symptoms is increasingly important in providing treatment toxicity information. However, observer-based scoring systems such as the CTCAEs which incorporate the LENT-SOMA scales are not adapted for patient-based reporting. We aim to (1) report the late toxicity in patients following head and neck radiotherapy using a LENT-SOMA patient-based questionnaire, (2) describe how the responses help to improve the questionnaire and (3) adapt the questionnaire for patient reporting using CTCAEs. METHODS: A 31-item LENT-SOMA patient questionnaire was administered prospectively to 220 patients pre-treatment and at eight time periods post-radical head and neck radiotherapy over 3 years. Exploratory factor analysis was carried out and questionnaire reliability was evaluated using Cronbach's alpha coefficient. RESULTS: At 3-years follow-up, grade 3/4 toxicity was recorded for xerostomia (44%), hoarseness (14.3%), altered taste (6.1%) and oropharyngeal pain (1.9%). Factor analysis indicated that questionnaire division according to anatomical sub-site was reasonable. Cronbach's alpha was 0.851 (95% CI: 0.820-0.883) indicating high reliability. Good compliance was obtained with all questions except for the 'weight loss' item. A satisfaction survey showed that the questionnaire was clear and concise. Teeth and mandible sections have been removed. Dietary change due to xerostomia has been incorporated in line with CTCAEs. LENT-SOMA scoring of analgesic needs and dysphagia not described in CTCAEs were found useful and have been retained. CONCLUSIONS: The questionnaire has enabled reporting of late toxicity and the responses have enabled refinement of the questionnaire. It is reliable, feasible and has been validated for patient-based collection of CTCAEs late toxicity data.

The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer.

OBJECTIVES/HYPOTHESIS: The objectives were to measure the degree of trismus induced after radiation therapy for nasopharyngeal cancer and assess its progress over time. STUDY DESIGN: A prospective, single-armed measurement study with long-term follow-up. METHODS: Seventeen patients with nasopharyngeal cancer treated between 1997 and 1999 were studied. Patients were given radiation therapy with bilateral parallel-opposing ports of 45 Gy, 25 fractions, then with a reduced volume to 68.4 to 70.2 Gy. The end point was the degree of trismus, which was measured by serial changes of the maximal interincisal distance (MID) at various specified time points before, during, and after radiation therapy. RESULTS: During the 9 weeks of radiation therapy there was no significant change of MID (normalized MID ranged from 99.8% to 97%). The rate of decrease during this period was 1.3% per month. After radiation therapy there was a rapid decrease of MID between 1 and 9 months (normalized MID values at 1 and 9 mo were 95.5% +/- 3.1% and 74.2% +/- 5.7%, respectively). The rate of decrease during this period was dramatic (2.4%/mo). One year after radiation therapy, the rate of decrease became slower but was still measurable (0.2%/mo for the period from 12 to 24 mo). For the period from 24 to 48 months. the rate dropped to 0.1% per month. By the end of 48 months, normalized MID was 67.8% +/- 7.6%. CONCLUSION: By means of measurement over a period of time, it was found that patients with nasopharyngeal cancer had a mean decrease in initial interincisal distance of 32% at 4 years after radiotherapy. The trismus process evolved at different rates. It was rapid at 1 to 9 months after radiation therapy, then became slower and protracted over later years.

Odontogenic infection pathway to the submandibular space: imaging assessment.

The aims of this study were to determine the pathways of odontogenic infection spread into the submandibular space and their relationship to the clinical symptoms. Computerized tomography (CT) and magnetic resonance (MR) images of 33 patients with submandibular involvement were analyzed. The spread of infection was evaluated by lateral asymmetry of the shape and density of the fascial spaces and tissues, and by obliteration of the interfascial fat spaces. Imaging findings were classified into three types: in 19 patients (57.6%), infection spread through the mylohyoid muscle or sublingual space (type I). In five patients (15.2%), infection spread through the bony structures of the mandible with periosteal reaction or perforation of the cortical plate (type II) and was associated with relatively mild symptoms. In four patients (12.1%), infection spread from the masticatory space (type III). Seven of 11 patients with dysphagia or fever showed submandibular involvement spreading into the parapharyngeal space. CT and MR imaging clearly demonstrated different pathways of the spread of odontogenic infection into the submandibular space, which influenced the manifestation of clinical symptoms.

The use of positron emission tomography and computed tomography in the assessment of trismus associated with head and neck malignancy.

The assessment of head and neck cancer has traditionally involved clinical examination and anatomical imaging by computed tomography (CT) or magnetic resonance imaging (MRI). We present a case where a problem of clinical confusion and inconclusive radiology was resolved by the use of positron emission tomography (PET) coregistered with CT.

An association between imaging and acute posttraumatic ear bleeding with trismus.

OBJECTIVES: Computed tomography findings for each of 94 patients with unilateral ear bleeding and trismus correlated with either comminuted temporal bone fracture (26 cases) or bilateral temporomandibular joint fracture (68 cases). STUDY DESIGN: Ninety-four patients with post-traumatic unilateral ear bleeding and 10 asymptomatic adults underwent coronal computed tomography examinations of their temporomandibular joints. Of these, 26 patients with intact temporomandibular joints underwent axial computed tomography of the temporal bones. For 23 of the 94 symptomatic patients, computed tomography was the final imaging procedure; for the other 71 symptomatic patients, it was the first imaging procedure. Quantifications of the radiation dose and the per-patient cost of imaging were performed. Measurement of the maximal mandibular movements in vertical and horizontal directions was performed clinically in the 10 asymptomatic adult control subjects and in the 94 patients with trismus and ear bleeding. RESULTS: Ten control subjects had maximal opening values of 40 mm or more, and horizontal movement exceeded 24 mm. In 68 symptomatic patients, coronal computed tomography demonstrated bilateral fracture: there was bilateral high condylar fracture in 35 patients, and there was ipsilateral to the bleeding high condylar fracture with contralateral subcondylar fracture dislocation in 33 patients. Axial computed tomography scans in 26 symptomatic patients with intact temporomandibular joints demonstrated comminuted petrous bone fracture ipsilateral to the ear bleeding. CONCLUSIONS: Patients with post-traumatic ear bleeding associated with trismus should first be evaluated by computed tomography. Any other initial procedure doubles the radiation dose as well as the cost of the imaging.