Oral Health Related Quality Of Life In Head And Neck Cancer Patients Visiting A Tertiary Center In Central Nepal

doi:10.21203/rs.3.rs-3262516/v1

Background: Head and Neck Cancer (HNC) cases are rising every year. It is associated with various manifestations in oral cavity and leads to a compromise in Oral Health Related Quality of Life of the pateints.

Objectives: This study was conducted to assess Oral Health Related Quality of Life (OHRQoL) in Head and Neck cancer patients and compare it with their apparently normal counterparts.

Methods: A comparative cross–sectional study was conducted among 65 cases of HNC and their apparently normal counterparts visiting a tertiary cancer center in central Nepal. Diagnosed cases of HNC who were 18 years or more, providing consent and willing to participate in the study were taken as cases and 65 apparently healthy attendants after matching of age, sex and socio-economic status were taken as controls. Terminally ill, pregnant and those not providing consent were excluded from the study. Translated and validated OHIP-14 questionnaire was used to assess the Oral Health Related Quality of Life. Stage of cancer, site of cancer and time since diagnosed was assessed from the patient’s record file. Response to OHIP-14 items were recorded on a likert scale and the mean score was calculated. The results were statistically analysed using Mann-Whitney U test and Kruskal Wallis test.

Results: Majority of the participants belonged to upper lower socio-economic class. Mean OHIP -14 score in case group and control group were 23.91±9.71 and 6.54±4.86 respectively and the difference was statistically significant (p<0.001). The highest affected domain in case group was psychological discomfort (6.10±1.49) and that in control group was physical pain (2.50±1.70). In salivary gland tumor, the highest affected domain was handicap. In all other tumors, psychological discomfort was the highest affected domain and the values were not statistically significant.

Conclusion: There is an impairment of the OHRQoL in HNC patients which is higher than their normal counterparts.

Dental

Head and Neck Cancer

Quality of life

OHIP

Head and Neck cancer (HNC) is responsible for around 900,000 cases and over 400,000 deaths globally each year.¹ The term HNC consists of group of tumors that arise from the lip, oral cavity, tongue, tonsil, oropharynx, hypopharynx, nasopharynx, nose and para nasal sinus, larynx, parotids and the thyroid.² While HNC form one of the most common cancers in South and Southeast Asian countries, they form only 1–4% of all cancers in the western world.³. This is mainly attributed to the prevalence of oral habits like tobacco, areca nut in different forms and alcohol in this region.^4–6 In context of Nepal, 30.8% people consume tobacco, 17.4% consume alcohol and 20% consume areca nut.^7,8 The actual burden of HNC in South Asia is much greater than reflected through the existing literature and hence can be regarded as ‘tip of iceberg’ situation.⁹ With a change in lifestyle, dietary habits, and high consumption of tobacco and alcohol, the incidence of cancer is increasing in Nepal.⁷

HNC may present unique threats to the well-being, sense of self, social functioning and quality of life (QoL) of an individual. Patients with HNC are often confronted with oral dysfunction, swallowing and speech problems in addition to physical and psychological problems. Similarly, treatment for HNC may lead to complications like mucositis, pain, mucosal sensitivity, dry mouth, altered or reduced taste, mucosal and bony necrosis, increased risk of dental caries, difficulty with denture fixation, altered esthetics, reduced mobility of tongue, lips and jaw and limitation of mastication and swallowing and difficulty in maintenance of oral hygiene.¹⁰ As they dramatically influence physical, emotional and social quality of life, these adverse effects are of critical importance for nursing care during the period of cancer battle.

In cancer treatment, importance has always been given towards the prolongation of the patient’s survival.¹¹ However, quality of life (QoL) is an important aspect of well-being for a patient.^12–14 It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment. WHO has recognized the OHRQoL as an important segment of oral health program.¹⁵ OHRQoL is a multidimensional construct that includes a subjective evaluation of individual’s oral health, functional well-being, emotional well-being, expectations and satisfaction with care and sense of self.^16,17 The impact of a condition on an individual’s quality of life is a particular and subjective analysis¹⁸ and obtaining any report directly from patients on their perspective of disease impact adds a new dimension in disease management. HRQoL is usually assessed using cancer specific measures and only limited studies have been conducted using a generic tool that allows comparison with general population.

Assessment of OHRQoL allows for a shift from traditional medical criteria to assessment and care that focuses on a person’s social & emotional experience and physical functioning in defining appropriate treatment goals and outcomes.¹⁹ It will also ensure the patient’s role as a more active member of the treatment team and follow their treatment plan and thus a better health maintenance service can be provided.²⁰

Baseline quality of life has also been associated with clinical outcomes in cancer treatment.²¹ This can also be helpful in identifying the type of palliative care required for the patient. This will help health care professionals to modify their traditional medical approach in treatment of the disease by prioritizing problems and identifying preferences. It will also help to monitor response or changes to treatment and create a mechanism to communicate with policymakers to reveal the importance of oral health and helps to formulate better health care policies for such patients.

A study done in Brazil²² shows that there is a decreased OHRQoL (increased OHIP score) in HNC patients in comparison to cancer free patients. No study has been published to assess the quality of life in HNC patients in Nepal.. The present study will provide baseline information regarding various oral health related problems HNC patients are facing which can be compared with post-treatment data so that improvements on the basis of patient reported outcome can be analyzed. A modification in traditional treatment approach can be done by prioritizing problems and identifying preferences.

The aim of the current study was to assess the oral health related quality of life in HNC patients and compare it with their normal counterparts.

This was a comparative cross-sectional study conducted from 15th June to 15th July,2020 in ENT, HNC unit of BPKMCH, Chitwan. Ethical clearance was obtained from IRC, BPKIHS (Ref no. 30/077/078-IRC). Pre-treatment patients who were 18 and above and diagnosed with HNC were selected purposively in the study and their OHRQoL was compared with their normal counterparts.

Teminally ill patients, patients undergoing treatment for cancer or on follow up, pregnant women and those diagnosed with any form of cancer were excluded from the study. There were 130 patients included in our study, 65 in each group. The sample size was calculated using the difference of mean OHIP score between pre-treatment HNC patients and cancer-free patients taken from a previous study done in Brasil²² in 2015.

Written informed consent was taken from 65 HNC patients and their normal counterparts after matching for age (± 5 years), gender and socio-economic status (using Modified Kuppusamy Scale).The interview was taken in ENT, HNC unit, BPKMCH. Patients were approached after their appointment was over with the concerned doctor. The patients were asked to sit comfortably in a chair. Personal Protective Equipment were used by the interviewer and adequate distance was maintained while taking the interview for personal protection from COVID-19. Demographic details were recorded from each participant. Site of cancer, stage and duration of diagnosis were recorded from from patient’s record book. Pre-testing of the questionnaire was done on 15 patients before the start of the study.

Questionnaire

OHIP (Oral Health Impact Profile) aims to apprehend impacts that are related to oral conditions in general, rather than impacts that may be attributed to specific oral disorders or syndromes. The OHRQoL construct is divided into seven dimensions. They are: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. OHIP-14 is a shorter version of OHIP 49 questionnaire and consists of the 14 statements, two in each domain. Respondents are asked to indicate on a five-point Likert scale how frequently they experienced each problem within a reference period, for example 12 months. Response categories for the five-point scale are: "Very often", "Fairly often", "Occasionally", "Hardly ever" and "Never". For data entry, responses are coded 0 (never or not applicable), 1 (hardly ever), 2 (occasionally), 3 (fairly often) or 4 (very often).

Data handling

Data was entered in Microsoft Excel 2016 and exported to statistical package for social sciences software (SPSS) version 11.5 for statistical analysis.

Descriptive analysis : Mean, standard deviation, median, interquartile range, proportion were calculated with graphical and tabulated presentation to illustrate age, gender, ethnicity, SES, site of cancer and stage of cancer.

Inferential analysis : Mann-Whitney U test was used to compare the mean scores in each domains and means of OHIP-14 between cases and controls.

Spearman correlation was used to compare age & OHIP-14 score and time since diagnosis and OHIP-14 score. Kruskal Wallis test was used to compare different tumor sites with mean scores in different domains.

A total of 130 patients were included in the study out of which 65 were patients diagnosed with HNC. Remaining 65 were control group selected after matching of age, sex and socioeconomic status among the attendants of HNC patients visiting BPKMCH, Bharatpur. There were 41 (63.1%) males and 24 (36.9%) females in each group. The mean age (SD) of the participants was 48.13 (14.57) years. Out of total participants, 111 (90%) were Hindu by religion. Hill Brahmin/Chhetry was the major ethnic group comprising of 20 (30.8%) in cases and 33 (50.8%) in control group. Majority of the participants belonged to upper lower class (78.5%) (Table 1). The difference in mean OHIP-14 score between participants with different SES was not statistically significant. A weak positive correlation was seen between age of the participants and OHIP-14 score (r_s=0.12, p=0.16). Among different types of HNCs, highest prevalence was seen in cancer of Oral and Oropharyngeal region. Lowest prevalence was seen in cancer of Salivary gland and Nasal & Paranasal sinus (4.6% each).

Figure 1 shows that there was a weak correlation between time since diagnosis and OHIP-14 score in HNC patients. The mean OHIP-14 score when compared between different stages of cancer didn’t show statistically significant result (Table 2).

Table 1: Socio-demographic Profile

Characteristics		Case	Control		Total (N=65)
Age (unit) Mean ( SD)		48.18(14.142	48.08(15.10)		48.13(14.57)
Gender n (%)
Male [n (%)]		41 (63.1%)	41 (63.1%)		82 (63.1%)
Female [n (%)]		24 (36.9%)	24 (36.9%)		48 (36.9%)
Ethnicity n (%)
Hill brahmin/Chhetry		20 (30.8%)	33 (50.8%)		53 (40.8%)
Newars		0	5 (7.7%)		5(3.8%)
Hill Dalits		5 (7.7%)	8 (12.3%)		13(10%)
Terai/Madhesi Dalits		2 (3.1%)	0		2 (1.5%)
Hill/mountain janajati		17 (26.2%)	11 (16.9%)		28(21.5%)
Terai/Madhesi janajati		10 (15.4%)	4 (6.2%)		14(10.8%)
Terai/Madhesi other		6 (9.2%)	2 (3.1%)		8(6.2%)
Muslim		5 (7.7%)	2 (3.1%)		7(5.4%)
Religion n (%)
Hindu		55 (84.6%)	62 (95.4%)		117(90%)
Buddhist		4 (6.2%)	0		4(3.1 %)
Muslim		5 (7.7%)	2 (3.1%)		7( 7%)
Christian		0	1 (1.5%)		1( 1%)
Kirat		1 (1.5%)	0		1(1 %)
Socioeconomic status n (%)
Upper	0			0		0
Upper middle	3 (4.6%)			3 (4.6%)		6 (4.6%)
Lower middle Upper	11 (16.9%)			11 (16.9%)		22 (16.9%)
Upper lower	51 (78.5%)			51 (78.5%)		102 (78.5%)
Lower	0			0		130

Clinical TNM staging data shows the number of patients with stages of the disease I, II, III and IV were 8 (12.3%), 9 (13.8%), 22 (33.8%) and 26 (40%) respectively. The median time since diagnosis was 10 days (Interquartile range (IQR): 7-30). There were six different types of HNC patients on the basis of site in this study among which 32 (49.2%) belonged to oral and oropharyngeal cancer followed by laryngeal and hypopharyngeal cancer and thyroid cancer. Chronbach’s alpha value of the OHIP-14 questionnaire was found to be 0.87 (good internal consistency) and intra-class correlation coefficient for test-retest reliability for single examiner was found to be 0.92 (excellent test-retest reliability).

Figure 2 shows the frequency of reported problems (items) related to oral condition in the preceding 1 month by the participants. There were 13 (20%) participants in control group who had no impact due to oral health conditions whereas no such participants were there in case group. All the participants in case group felt self-conscious, tense and less satisfying life due to HNC whereas 32.3%, 40% and 36.9% participants from control group felt impact in these items respectively. Similarly, almost all (96.9%) of HNC patients felt painful aching and 98.5% felt total inability to function whereas only 32.5% and 1.5 % of participants from control group reported impact in these items respectively.

Table 2: Mean OHIP-14 score with different stages of cancer

Stage of cancer	Mean OHIP (SD)	P value ^
Stage I	22.63 (8.93 )	0.072
Stage II	19 ( 4.98)
Stage III	22.05 ( 8.25)
Stage IV	27.58 ( 11.41)
^Kruskal Wallis test

There are seven different domains in OHRQoL. In case group, psychological discomfort had the highest mean score of 6.10±1.49 and median 6 (interquartile range 2) followed by ‘handicap’ domain 5.56±1.74 and ‘Physical pain’ domain 4.06±2.29. Whereas, in control group, ‘Physical pain’ domain had highest score 2.50±1.70 followed by ‘psychological discomfort’ domain 1.24±1.54. The OHIP-14 score of case group was 23.91±9.71 (median 21, IQR 14.5) and that of control group was 6.54±4.86 (median 6, IQR 4.5) and the difference was statistically significant (<0.001). Similarly, the mean OHIP-14 score in case group was 23.91±9.71 and that in control group was 6.54±4.86 and the difference was statistically significant (p<0.001) (Table 3).

Table 3: OHIP scores in different domains of OHIP-14

Domains	CASE (n=65)		CONTROL (n=65)		P -value^
Domains	Mean score(SD)	Median (IQR)	Mean score(SD)	Median (IQR)	P -value^
D1 (functional limitation)	1.43(2.08)	0.00 (0-2.5)	1.04 (1.48)	0 (0-2)	0.651
D2 (physical pain)	4.06(2.29)	3 (2-6)	2.50 (1.70)	3 (1-4)	0.001
D3 (psychological discomfort)	6.10(1.49)	6 (5-7)	1.24(1.54)	0 (0-2)	<0.001
D4 (physical disability)	1.53(2.06)	0 (0-3)	0.50(0.90)	0 (0-1)	0.006
D5 (psychological disability)	2.01(1.67)	2 (1-3.5)	0.55(0.88)	0 (0-1)	<0.001
D6 (social disability)	3.18(1.75)	3 (2-4)	0.38(0.74)	0 (0-1)	<0.001
D7 (handicap)	5.56(1.74)	6 (4-6)	0.29(0.49)	0 (0-1)	<0.001
OHIP-14 score	23.91(9.71)	21 (16-30.5)	6.54(4.86)	6 (3.5-9)	<0.001
^ Mann-Whitney U test

Table 4: Comparison of different sites with the mean scores of each domain

Sites	Laryngeal & hypopharyngeal	Nasal cavities & PNS	Nasopharyngeal	Oral & oropharyngeal	Salivary gland	Thyroid	p-value
D1	2.55(2.50)	0.00(0.00)	1.16(1.16)	1.75(2.32)	0.33(0.57)	0.50(1.24)	0.136*
D2	4.77(2.04)	5.00(2.64)	4.00(2.89)	4.5(2.40)	3.66(1.15)	2.25(1.05)	0.090*
D3	7.11(1.26)	6.00(1.73)	6.50(1.04)	6.1(1.62)	5.00(1.00)	5.41(1.16)	0.075*
D4	1.44(1.23)	3.00(2.64)	2.16(3.06)	1.93(2.24)	0.30(0.5)	0.16(0.38)	0.066*
D5	2.55(1.58)	3.33(2.08)	2.50(1.04)	1.96(1.80)	2.66(1.52)	1.00(1.20)	0.104*
D6	4.11(1.36)	3.33(1.15)	3.33(1.63)	2.93(2.1)	3.33(1.52)	3.00(1.12)	0.582*
D7	6.11(1.45)	5.66(0.57)	5.66(2.33)	5.40(1.89)	5.66(2.08)	5.50(1.50)	0.902*
OHIP-14 score	28.67(7.74)	26.33(7.77)	25.33(6.9)	24.63(11.77)	21(4.15)	17.83(4.15)	0.158
* Kruskal Wallis test

When compared with different HNC sites, only salivary gland tumors had highest OHIP-14 score in ‘handicap domain’ (5.66±2.08). All other sites had highest score in ‘psychological discomfort’ domain. The mean scores of different types of HNC when compared in different domains didn’t show statistically significant difference. Laryngeal and hypopharyngeal cancer group had the highest mean OHIP score (28.67±7.74) and thyroid cancer group had the lowest OHIP-14 score (17.83±4.1). The difference in OHIP-14 score in different cancer site was not statistically significant (Table 4).

It was a comparative cross-sectional study conducted in a tertiary cancer center in central Nepal. This study was conducted to assess baseline OHRQoL of HNC patients and compare it with their normal counterparts. To our knowledge, this is the first study in Nepal that assesses OHRQoL in HNC patients and there are limited studies of similar type world-wide. Sixty-five pre-treatment cases of HNC visiting B P Koirala Memorial Cancer Hospital, Bharatpur were included in this study. Attendants of the patients after matching age, gender and socio-economic status were selected as controls.

Mean age of the participants was 48.13 ± 14.57 years which is similar to the mean age of HNC patients in another tertiary center in Nepal.²³ The ratio of male to female in our study was 1.7:1. This is similar with the studies conducted in other parts of Nepal.^24,25 In our study, majority of the participants (78.5%) belonged to upper lower socioeconomic status. This was in line with the study conducted by Punita et al.²⁶ and Ganesh et al.²⁷ in India and Hwang et al.²⁸ in Canada. Conway et al.²⁹ concluded in a meta-analysis that the risks of developing oral cancer were higher for those with low socioeconomic status (SES) than for those who were better off. Lower socioeconomic status is linked with development of HNC³⁰ and are also found to have a significantly higher prevalence of tobacco and alcohol use than did high socio-economic group.³¹ Tobacco and alcohol consumption are established risk factors for HNC.³² In a study conducted by Agrawal et al.³³ in New Delhi, India, the result was slightly different. They found that majority (53%) of the participants belonged to middle or high class.

The site with highest incidence of cancer was oral and oropharyngeal in both the genders. Only oral cancer and cancer of lips constituted 27.7% of the total cases (not shown in table). This is in line with the report of Cancer Registry, Nepal (2018)³⁴ and WHO-cancer country profile,2014,³⁵ in which lip and oral cavity had the highest prevalence among HNC. After that, larynx and hypopharynx (19.5%) in males and thyroid (41.7%) in females had the highest prevalence. This is similar to the study conducted by Mourad et al.³⁶ in USA and Mc Carthy et al.³⁷ in England. Cancers of larynx are 4 times more common in males than in females³⁸ and are associated with tobacco consumption the prevalence of which is very high in South-Asian region. One probable reason for high presentation of laryngeal cancer could be the lower chances of self-screening by the individual which delays the referral to a physician at an appropriate time. The incidence of thyroid cancer is higher in females than in males. This is particularly notable because oestrogen level is proved to be one of the risk factors of thyroid cancer and the oestrogen level is actually higher in women than in men.³⁹ Regardless of cancer sites, scores in each domain were not significantly different in our study. It means that HNC of any site may equally affect the OHRQoL.

The median time since diagnosis was 10 days in our study. The time since diagnosis did not seem to have a significant correlation with OHIP-14 score. There might be a heterogeneity in self-realization of impact of the disease in different domains of OHRQoL construct. We took the data of last 30 days and 80% of the patients had their diagnosis within that period.

In this study, what we found is majority of the participants (73.3%) presented with significantly advanced stage (40% stage IV and 33.3% stage III) of cancer. Our study confirms with the findings from the study done by Chhetri et al.²⁴ in Eastern Nepal. Patel et al.⁴⁰ and Dhull et al.⁴¹ also have reported about the late stage presentation in HNC patients. Most of the participants in our study were from lower socio-economic background and there is a significant association between SES and stage of presentation of cancer.³³ Similarly, lack of knowledge about cancer, the role of unavailability of primary health care, lack of timely screening and diagnosis, unaffordability to reach higher centers and use of drugs for palliative care without prescription cannot be underestimated in this matter. The highest mean OHIP-14 score was seen in stage IV patients but no statistically significant difference was seen in the association between stage of cancer and OHRQoL.

OHRQoL in HNC patients was found to be significantly degraded in comparison to the general population in our study. This finding is similar to that in the study done by Stuani et al.²² The head and neck region includes numerous delicate dainty structures necessary for basic physiologic function. On the basis of tumor size, location and type of treatment, HNC can affect varying degree of structural antonyms, and functional hindrance comprising of well-being, self-esteem, and social interactions.⁴² Cancer brings tremendous social distress, physical and psychological suffering, hardship to patients and their families. There are seven different domains in OHIP-14. When compared among the different domains between cases and control groups, the mean score was significantly higher in case group in all domains except functional limitation. This could be because OHIP places greater emphasis on psychological and behavioural outcomes and better meets them rather than functional outcomes.⁴³

One of the vital concern reported by HNC patients is disfigurement.⁴⁴ The leading difficulties lie within the area of social interaction, with people being subjected to unwanted intrusions such as staring or comments.⁴⁵ Phlegm, dry mouth, halitosis, need to spit and clear the throat are often associated with HNC. This could be unpleasant to both the patient and next of kin and it discourages the social interaction. Disfigurement also has a role as a physical barrier between the subject and the partner, thus hindering sexuality within the couple.⁴⁶ Additionally, dysphagia and other different types of pain exists in HNC patients due to the obstruction and infiltration of nearby structures by the tumor⁴⁷ and it is a known fact that pain is associated with psychological factors such as anxiety and depression.⁴⁸

Physical pain was the most affected domain in control group. This is similar to the findings of the study conducted by Hongxing et al.⁴⁹ in China and Hussain et al.⁵⁰ in India. Similar findings were also seen in the study done by Dahl et al.⁵¹ in Norway and Daly et al.⁵² in the UK. This finding of our study might be explained through linking the prevalence of oral diseases in developing countries like Nepal due to the lack of education and poverty. The most common dental problem of the Nepalese is dental decay and periodontal diseases and one fourth of the population are affected by orofacial pain.⁵³

Historically, oral health has been separated from the body when considering about the overall health status. Nevertheless, recent studies have emphasized that oral disorders have emotional and psychosocial consequences similar to other disorders.⁵⁴ This is reflected in our research too as ‘Psychological discomfort’ was the highest affected domain in case group. This finding was in agreement with a study by Stuani et al.²² in Sao Paulo, Brazil. Patients of HNC experience it as more emotionally traumatic than other cancers.⁵⁵ Patients also experience the HNC diagnosis as life threatening, a sense of alarm that is often further worsened by an advanced stage and life-altering therapies. Patients often undergo a diversity of emotions, such as fear of death, uncertainty about the future, and social concerns⁵⁶ and are faced with often undesirable changes in appearance and vital functions. The obscurity can persist after the diagnosis, as future tests may be needed to determine the extent of the disease. Assimilation of diagnostic and treatment related information further adds stress on patients. The acute stress and associated insomnia risks might affect executive functioning, involving the capacity to reason, solve problem, and anticipate.⁵⁷ Ultimately, this may lead to anxiety, uncertainty and hopelessness in patients. There were 8 (12.3%) participants from the control group who had zero score in OHIP-14 indicating no impact from oral conditions whereas there were no such participants in case group. The findings from this study revealed that the prevalence of impacts in general population determined by the OHIP-14 was 87.7%. This value is quite high compared to reports from the study done by Sanders et al.⁵⁸ in which the impact prevalence of 16.5% was reported amongst Australians using the same OHIP-14 scale, 15.3% in Americans and 15.7% amongst Australians using 7 item OHIP questionnaire. This might be attributed to the higher prevalence of oral diseases and orofacial pain in Nepalese population.⁵³ This might also be due to the differing perceptions of oral health in different populations or due to reporting biases. Almost all the HNC patients responded greater than zero score in items from psychological discomfort and handicap. The highest number of HNC patients gave score zero to the ‘interruption of meal’ item. This is because of the different sites of HNC in our study which might not affect chewing or swallowing of foods. Self-medication of analgesics or under prescription of physicians might also be a possible contributing factor for it.

STRENGTHS AND LIMITATIONS

This is a matched comparative cross-sectional study. Age, gender and socio-economic status have been matched across two groups as OHRQoL can have association with these variables. Modified Kuppusamy scale was used to assess socioeconomic status in our study. SES can impact health outcomes and is dependent on many variables, such as income, educational attainment, housing and family structure. Modified Kuppusamy scale uses family income, occupation of the family head and education level of family head to calculate SES. Most of the studies are limited to the use of income or education for the assessment of socio-economic status where much social and cultural capital implicit in SES is lost.

However, our study is not without limitations. The observed impacts in patients may be due to other oral conditions, not just due to Head and Neck Cancer. This could have been addressed through the use of cancer specific HRQoL. Future research should include such cancer-specific assessment of OHRQoL. Participants from different ethnic groups were assessed in our study. The cultural experiences of the different ethnic group differ and may ultimately influence the impact profile of individuals. As the participants may also perceive the remote events as recent ones, there are chances of telescopic bias also. Moreover, the sample was selected conveniently in this study, the external validity might be compromised.

The present study revealed that HNC impacted greatly on oral health, well-being and functioning of the participants. The findings of this study hint towards a need of psychological counselling in HNC patients after the diagnosis of this disease. Also, many of the patients’ issues in HNC are related to problems of the oral cavity. Cancer patients require care provided by dental practitioners both for the prevention of oral-related morbidity and its management because of the challenges conferred by the disease and its treatment. Using the association between oral health conditions and quality of life can be an effective mechanism to communicate with policymakers to reveal the importance of oral health.

Ethical Approval and consent to participate

Ethical approval was obtained from Institutional Review Committee (IRC), B.P.Koirala Institute of Health Sciences (Ref. NO 30/077/078-IRC)

Written informed consent was taken from 65 HNC patients and their normal counterparts after matching for age (± 5 years), gender and socio-economic status (using Modified Kuppusamy Scale).

Consent to publish

Not applicable

Competing interests

All authors declare no competing interests.

Authors' contributions

All authors contributed in concept and designing of the study. RK and DKG collected the data. RK analyzed the data. RK and SKA prepared the manuscript. Final manuscript was reviewed by all the authors.

Funding

None

Availability of data and materials

All relevant data is provided in this manuscript. Further details can be obtained by contacting the corresponding author.

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No competing interests reported.

Oral Health Related Quality Of Life In Head And Neck Cancer Patients Visiting A Tertiary Center In Central Nepal

Status:

Version 1

Abstract

Figures

INTRODUCTION

METHODOLOGY

Questionnaire

Data handling

RESULTS

DISCUSSION

STRENGTHS AND LIMITATIONS

CONCLUSION AND RECOMMENDATIONS

Declarations

References

Additional Declarations

Status:

Version 1