Evaluation of Oral Health Status and Quality of Life of Head and Neck Cancer Patients after Radiation Therapy

Introduction Neoplasm of the head and neck can be treated surgically, by radiation, chemotherapy, or using combination of these methods. In contrast to surgical and radiation treatment which mostly have a local effect, chemotherapy in addition to local have also a systemic effect. Both XRT in oral region and chemotherapy can affect oral health. The aim of this study was to assess the oral health status and quality of life in patients with head and neck cancer after receiving radiation therapy. Material and Methods Quantitative, analytical and cross-sectional research methods along with the application of UW-QOL questionnaire version 4, were used. Seventy one patients of the outpatient facilities at two cancer hospitals in the state of Paraíba, Brazil, were included in the study. Oral health status was evaluated using the Lockhart and Clark criteria. Linear Poisson and Logistic Regression tests were applied to assess associations between the variables using a significance level of 5%. Results Of the total number of patients, 71.83% were male, the average age was 62 years and 57.74% were non-Caucasian. The group that received dental monitoring and follow-up attained the highest (830.13) Quality of life scores, including: “pain” (93.13) and “taste” (83.07). The highest score for oral health in the group that did not receive dental monitoring and follow-up treatment was 4.08 for “oral hygiene”. Conclusion Dental monitoring and follow-up should begin before radiation therapy, given that both the illness and methods used for the treatment negatively affect patients’ quality of life.


INTRODUCTION
It is estimated that 13% of deaths in 2007 were caused by some form of cancer and 80% of those deaths occurred in countries with low or middle income per capita.The World Health Organization estimates that by 2030, 27 million new cases of cancer will be diagnosed, 17 million people will die of cancer related causes and 75 million people will be living with cancer [1].
Head and neck cancer can be treated by: surgery, radiation therapy (XRT), chemotherapy (chemo) or a combination of the three depending on the definitive diagnoses, the stage and location of cancer; patient's overall health and healthcare services available (physical and human resources).Each of the above treatment methods involves distinct procedures.Surgery is performed directly in the area afflicted by cancer and may result in functional and/ or aesthetic limitations.XRT has a location-specific effect while chemo has a systemic effect.These last two treatment methods impair the integrity and functioning of oral cavity because they destroy not only neoplastic cells, but also normal cells at the same time [2,3].
Most patients diagnosed with head and neck cancer are submitted to high doses of XRT in broad radiation fields that include oral cavity, maxilla, mandible and salivary glands.Antineoplastic therapy is therefore associated with various adverse reactions which may occur in both, acute phase (during the treatment or in the weeks immediately after) or chronic phase (months or years after XRT).The severity of acute oral complications will depend on how much these structures are included in the radiation field.The main side effects of XRT are: radiodermatitis, mucositis, xerostomia, opportunistic infections (viral, bacteria and fungicidal), dysgeusia, dysphagia, trismus, radiation tooth decay and osteoradionecrosis [4,5].
Even though technological advances in cancer treatment now offer the possibility of a cure, the mortality and morbidity of malign neoplasms raise questions about humanization of this type of care and its repercussion on the patients' quality of life (QOL), inviting to study not only its role as a procedure to prolong life but also how life can be lived better [6].
The definition of QOL has changed over the years and its precise meaning is now more subjective and multidimensional [7].In 1994, the WHOQOL Group established a concept that defined quality of life as "individuals' perceptions of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, parameters and social relationships".It is a broad concept with complex rami-fications that include individuals' physical health, their psychological state, level of independence, social relationships and relationship with their surroundings [6].
The active and early participation of oral health professionals aiming to develop preventive and therapeutic strategies and involvement in education and rehabilitation of these patients is indispensable when considering questions related to the quality of life during and after XRT [8].
This study aimed to assess oral health status and quality of life in two groups of head and neck cancer patients who completed radiation therapy treatment.One group received monitoring and dental guidance before radiation therapy and the other group did not receive any monitoring.

MATERIAL AND METHODS
The project was sent to the Research Ethics Committee at the Paraíba State University (UEPB), where it was approved and registered under number 0039.0.133.000-12.The patients signed the Informed Consent Form (TCLE), authorizing their participation in accordance with the Resolution No. 196/96 of the Ministry of Health, which regulates research on humans (Brazil, 1996).All information collected was treated as confidential maintaining patients' privacy.
A quantitative, analytical and cross-sectional study was performed by applying the Quality of Life Questionnaire elaborated by the University of Washington (UW-QOL), Version 4. This version was valid at the time of application.
The sample of patients with malign neoplasms in the area of head and neck who underwent XRT was chosen and included 71 patients who received exclusively external radiation therapy treatment, or in conjunction with surgery and/or chemotherapy, treated at the outpatient facilities at the Napoleão Laureano Hospital (HNL) and the Paraíba Assistance Foundation (FAP).
The following selection criteria were applied: both genders and >18 years who underwent external radiation therapy for malign tumor treatment in the region of head and neck, exclusively or in conjunction with surgery and/ or chemotherapy and were done with prescribed antineoplastic treatment.
Data were collected between February and November 2012 at both cancer reference hospitals in the state of Paraíba (Brazilian Northeast): at the HNL Stomatology outpatient facility in the city of João Pessoa, Paraíba and the outpatient facility assigned to the Oral Health Program Applied to Oncology (SBOnco), a service devoted to providing dental treatment to patients undergoing antineoplastic treatment at the FAP in the Dr. Ulisses Pinto Oncology Center in the town of Campina Grande, Paraíba.
The data were recorded in the validated Portuguese language version of the questionnaire known as UW-QOL version 4, prepared by the Department of Otolaryngology, Head and Neck Surgery at the University of Washington (2003) to assess the QOL of head and neck cancer patients.This questionnaire was widely used in a variety of studies.The questionnaire consists of 12 specific ques-tions about different aspects of QOL: pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood and anxiety [7].Oral health status was measured according to the Lockhart and Clark criteria [9], assessing teeth, periodontal status and oral hygiene.
The data were statistically analyzed using the R software version 2.15.1 (The R Foundation for Statistical Computing, Vienna, Austria).Two regression models were used: the Poisson Linear Regression model and the Logistic Regression Model (using a 5% significance level as the parameter).

RESULTS
The sample consisted of 71 patients with average age of 62 years who underwent head and neck radiation therapy.The variable "age" was grouped "less than 60" and "60+ years old" for the statistical test only and 60.56% of those interviewed were 60+ years old.Fifty-one patients (71.83%) were male, among which 41 (57.74%) were married and 57.74% were non-Caucasian (Table 1).
Given that none of the patients underwent cervical lymphadenectomy, the questionnaire variable "shoulder" was excluded from the study, thus leaving 11 of 12 categories.The patients' general quality of life was assessed by totaling the score of each one of the remaining 11 variables (total score) which ranged between 0 and 1,100.Composite score was calculated using the mean of the 11 variables ranging between 0 and 100, with 0 representing the worst quality of life and 100 the best.The patients were split into two groups, those who did not receive dental monitoring and follow-up and those who had monitoring and follow-up.The highest value of the total score was 830.13, pertaining to patients who had dental follow-up whereas the same group showed the highest composite score of 74.56 (Table 2).
Individual analysis of each one of the eleven UW-QOL questionnaire variables showed that patients who did not receive dental follow-up had the lowest score for the variable "recreation" (65.68) while the highest score was for "pain" (93.13).For the group that did not receive dental follow-up, the variable with the lowest mean score was "saliva" and the highest mean score was for "pain" (32.4 and 85, respectively).Assessment of oral health based on the Lockhart and Clark criteria [9], where the scores ranged between 1 and 5 (5 representing the worst oral health status) showed that patients who did not receive dental follow-up had the highest (the worst oral health) score in the three analyzed variables.The same group scored 3.8 for carious lesions meaning "visible" to "generalized extensive" decay.Their periodontal status showed score of 3.75 representing minimum dental mobility to advanced pathology (generalized mobility).Oral hygiene score of 4.8 represented precarious oral hygiene (Table 3).
The significant correlation between variables in patients who received dental treatment and those who did not receive dental monitoring was found for "saliva" (p<0.001) and "the presence of problems over the seven days prior to the interview" (p=0.0245).Regarding socio-biological-demographic conditions, no variables presented a statistically significant correlation (p<0.05)regardless of dental monitoring during radiation therapy.

DISCUSSION
This study assessed 71 patients who underwent radiation therapy in the region of head and neck; male patients outnumbered female patients by a factor of approximately 2.5:1.The average age was 62 years with majority of patients ≥60 years old and of non-Caucasian ethnicity.
Ângelo et al. [7] reported the average age for head and neck cancer patients 63.5 years, ranging between 40 and 83 years old, 73.2% were male, 56.1% were non-Caucasian and 46.3% were married.These results also corroborated with other studies [10,11].
Assessing the quality of life through the application of the UW-QOL questionnaire is a complex process, involving general and specific questions about different variables that affect head and neck cancer patients.Analysis of the results showed that the total UW-QOL mean score for those patients who did not receive dental monitoring or follow-up was relatively low -approximately half the maximum score possible -633.4and a composite score was 57.58.Similar results were found in the study carried out by Lima et al. [12].A Brazilian study on laryngectomized patients undertaken in the city of Curitiba, in which all patients received dental monitoring and followup presented a total UW-QOL mean score of 900.25 [13].
Weymuller et al. [14] in a prospective study on 549 patients with head and neck cancer who underwent XRT showed that in the first three months after the treatment the quality of life score was significantly lower.After six months the quality of life was improved with a tendency to improve for up to one year, attaining stability between one and three years after the treatment, as patients learn to live with treatment sequelae.Therefore both the postradiation therapy and pre-operative periods are critical phases when patients are in very vulnerable stage and their quality of life is compromised.
Upon analysis of the mean scores for each individual UW-QOL variable for both groups, it was observed that the variables "saliva", "taste" and "chewing" presented the worst scores for the group that did not receive dental monitoring and follow-up.These results also affected the total mean score for this group because "saliva" and "taste" were among best scored in the group that received dental monitoring and follow-up and the variable "chewing" received much higher score than the same variable in the other group.
UW-QOL questionnaire was used to assess the quality of life in 143 patients with oral cavity and oropharyngeal squamous cell carcinoma in the study conducted by Matias [15] who identified variables "chewing", "anxiety" and "swallowing" as the worst scored.On the other hand, the most relevant variables over the last seven days prior to application of the questionnaire were "pain", "swallowing", "chewing" and "saliva".These results were also observed in the study done by Ângelo et al. [7], where the variables "chewing" and "saliva" were among the worst scored, however the most relevant QOL variables over the previous seven days were "chewing'' followed by "saliva" and "speech".
"Chewing" was factor that reduced the QOL scores in the study conducted by Rogers et al. [16] and Andrade [17] which also proved relevant in our study.Similar results were obtained by other studies [18,19].Even though interviewed patients in our study were not significantly affected by cancer the variables "anxiety", "appearance" and "activity" appeared to contribute to difficulties in their recovery and return to normal social activity [17][18][19][20].Application of the Lockhart and Clark criteria [9] resulted in relatively high scores that were close to the maximum of 5, especially for oral hygiene where the group that did not receive dental follow-up scored 4.08 (5 = worst oral hygiene); high scores were observed for both groups in regards to tooth decay and periodontal status whereas the group that received dental monitoring and follow-up showed slightly better scores.These results were similar to the study performed by Gomes [21] where the majority of patients presented optimal oral hygiene (41.2%), precarious lesions (35.3%) and significant bone loss (41.2%) suggesting that cancer patients should be monitored by a dentist not only during and after antineoplastic therapy, but also before the beginning of this therapy.
There was a positive correlation between those patients who had and those who did not have dental monitoring before and during radiation therapy in relation to the variable "saliva" (p=7.85 -05 ).A positive correlation was also found between the group that received vs. the group that did not receive dental monitoring before and during radiation therapy in self-perception of oral health status (p=0.0245)due to the fact that patients who were monitored also received instructions how to deal with xerostomia.This correlation was also confirmed in the study done by Matias [15].According to Kielbassa et al. [8], to combat mucositis, hyposalivation, trismus, loss of taste, tooth decay and osteoradionecrosis -the most common oral clinical consequences of irradiation -active and early involvement of oral health professionals, in order to develop preventive and therapeutic strategies, is of vital importance to improve patients' quality of life during and after the radiation therapy.
It was observed that periodontal as well as dental status and/or use of implants are present as significant data in nearly all correlations, with significance levels varying between (p<2 -16 ) and (p=0.030) because they are directly related to chewing.Therefore, oral health status directly influenced the quality of life of patients that underwent head and neck radiation therapy, as observed in the study of Ângelo et al. [7], where the variable "chewing" showed the lowest mean scores but it was also the most relevant variable during the week prior to the interview.This fact illustrates the importance of "chewing" in the QOL assessment and points out the need for dental monitoring and follow-up during all stages of cancer treatment [21].

CONCLUSION
In general, the quality of life of all cancer patients was negatively affected both by the cancer and the treatment methods used to treat this condition.The most affected QOL variables vary greatly in different study groups with higher values obtained in the group that received dental monitoring and follow-up before, during and after the radiation therapy in both individual variables and total score.Since both the disease and therapeutic methods used to treat it compromise patients' and their families' quality of life, dental care should start even before the first application of radiation therapy.

KRATAK SADRŽAJ
Uvod Neo pla zme gla ve i vra ta se mo gu le či ti hi rur ški, zra če njem, he mi o te ra pi jom ili kom bi na ci jom ovih me to da.Za raz li ku od hi rur ške i te ra pi je zra če njem, ko je ima ju lo kal no dej stvo na obo le li deo te la, he mi o te ra pi ja ima i si stem ski efe kat.Ipak, zra če nje u pre de lu usne šu plji ne i he mio te ra pi ja mo gu uti ca ti na sta nje oral nog zdra vlja bo le sni ka.Cilj ove stu di je bio je da se pro ce ni sta nje oral nog zdra vlja i kva li tet ži vo ta bo le sni ka s kar ci no mom gla ve i vra ta na kon lečenja zra če njem.Ma te ri jal i me to de ra da U is tra ži va nju su ko ri šće ne kvan ti ta tiv ne, ana li tič ke i me to de pre se ka uz pri me nu upit ni ka UW-QOL, ver zi ja 4. Is pi tan je 71 am bu lant ni pa ci jent u dve ma on ko lo škim bol ni ca ma u dr ža vi Pa ra i ba u Bra zi lu.Sta nje oral nog zdra vlja je oce nje no na osno vu Lok har to vih (Loc khart) i Klar ko vih (Clark) kri te ri ju ma.Da bi smo utvr di li od nos is pi ti va nih va ri ja bli, pri me nje ni su li ne ar ni Po a so nov (Po is son) test i lo gi stič ka re gre si ja sa ni vo om zna čaj no sti od 5%.Re zul ta ti Od is pi ta nih bo le sni ka 71,83% su bi li mu škar ci pro seč ne sta ro sti od 62 go di ne, dok je 57,74% bo le sni ka bi lo ne kav kaske ra se.Gru pa is pi ta ni ka kod ko je je po sto ja la sto ma to lo ška kon tro la po ka za la je naj vi ši kva li tet ži vo ta (830,13) uklju ču ju ći "bol" (93,13) i "ukus" (83,07).Naj vi ša oce na za oral no zdra vlje u gru pi is pi ta ni ka ko ji ni su od la zi li na re dov nu sto ma to lo šku kon tro lu bi la je 4,08, i to za stav ku "oral na hi gi je na".Za klju čak Sto ma to lo šku kon tro lu bo le sni ka tre ba vr ši ti pre po čet ka pri me ne te ra pi je zra če njem za to što sa ma bo lest, kao i me to de ko ri šće ne u le če nju kar ci no ma, lo še uti ču na kva li tet ži vo ta ovih bo le sni ka.Ključ ne re či: neo pla zma; ra di o te ra pi ja; kva li tet ži vo ta; gla va; vrat; oral no zdra vlje UVOD Pro ce nju je se da je 13% smrt nih slu ča je va u 2007.go di ni na sta lo kao po sle di ca ne kog ob li ka kan ce ra, a od to ga se čak 80% smr ti do go di lo u ze mlja ma s ni skim ili sred njim pri ho di ma po gla vi sta nov ni ka.Svet ska zdrav stve na or ga ni za ci ja pro ce nju je da će do 2030.go di ne bi ti di jag no sti ko va no 27 mi li o na no vih slu čaje va kan ce ra, 17 mi li o na lju di će umre ti, a 75 mi li o na osoba će ži ve ti s kan ce rom [1].
Kan cer gla ve i vra ta se mo že le či ti hi rur ški, zra če njem, he mio te ra pi jom ili kom bi na ci jom ovih me to da, u za vi sno sti od konač ne di jag no ze, fa ze i lo ka li za ci je neo pla zme, op šteg zdrav stvenog sta nja bo le sni ka i do stup nih zdrav stve nih uslu ga (fi zič kih, ljud stvo).Sva ka od na ve de nih me to da le če nja uklju ču je raz li či te pro ce du re.Hi rur ško le če nje kan ce ra vr ši se di rekt no na obo lelom pod ruč ju i mo že do ve sti do funk ci o nal nih i/ili estet skih ogra ni če nja.Zra če nje de lu je na po seb noj lo ka ci ji, dok he mio tera pi ja ima si stem ski efe kat.Ove dve me to de le če nja na ru ša va ju in te gri tet i funk ci o ni sa nje usne šu plji ne, jer uni šta va ju ne sa mo neo pla stič ne će li je, već u isto vre me i nor mal ne će li je [2,3].
Ve ći na bo le sni ka sa di jag no zom kan ce ra gla ve i vra ta iz lože na je vi so kim do za ma zra če nja u de lo vi ma or ga ni zma ko ji uklju ču ju usnu šu plji nu, gor nju i do nju vi li cu i plju vač ne žle zde.An ti ne o pla stič na te ra pi ja je sto ga po ve za na s raz li či tim ne že ljenim re ak ci ja ma ko je se mo gu ja vi ti u akut noj fazi (to kom te rapi je ili u ne de lja ma ne po sred no na kon le če nja) ili hro nič noj fa zi (me se ci ma ili go di na ma po sle zra če nja).Te ži na akut nih oral nih kom pli ka ci ja će za vi si ti od to ga ko li ko su se ove struk tu re na šle u pod ruč ju zra če nja.Glav ni ne že lje ni efek ti te ra pi je zra če njem su: ra di o der ma ti tis, mu ko zi tis, kse ro sto mi ja, opor tu ni stič ke in fek ci je (vi ru sne, bak te rij ske i glji vič ne), po re me ćaj uku sa i gu ta nja, tri zmus, ka ri jes i oste o ra di o ne kro za [4,5].
Iako je teh no lo ški na pre dak u le če nju kan ce ra do veo do moguć no sti iz le če nja, mor ta li tet i mor bi di tet kao po sle di ca neo pla-zmi do vo de do no vih pi ta nja o hu ma no sti ove te ra pi je, od no sno nje nih po sle di ca na kva li tet ži vo ta bo le sni ka.Po treb no je ura di ti još do sta stu di ja ko je raz ma tra ju ne sa mo pro du že nje ži vo ta obo le lih oso ba, već i ka ko po bolj ša ti nji hov kva li tet ži vo ta [6].
De fi ni ci ja kva li te ta ži vo ta se pro me ni la to kom go di na i nje no pre ci zno zna če nje je sa da su bjek tiv no i vi še di men zi o nal no [7].Go di ne 1994.gru pa VHO QOL je de fi ni sa la kva li tet ži vo ta kao "per cep ci ju po je din ca o nje go vom po lo ža ju u ži vo tu u kon tek stu kul tu re i si ste ma vred no sti u ko jem ži vi u od no su na svo je ci ljeve, oče ki va nja, pa ra me tre i so ci jal ne od no se".To je ši rok po jam ko ji uklju ču je fi zič ko zdra vlje po je din ca, nji ho vo psi hič ko sta nje, ni vo ne za vi sno sti, dru štve ne od no se i od nos s okru že njem [6].
Ve o ma je zna čaj no ak tiv no i ra no uklju či va nje sto ma to lo ga i dru gih struč nja ka sto ma to lo ške pro fe si je u re ha bi li ta ci ju ovih bo le sni ka zbog raz vo ja pre ven tiv nih i te ra pij skih stra te gi ja, ka ko bi se po bolj šao kva li tet ži vo ta na kon zrač ne te ra pi je [8].
Cilj ove stu di je je bio da pro ce ni sta nje oral nog zdra vlja i kva li tet ži vo ta oso ba obo le lih od kar ci no ma gla ve i vra ta na kon te ra pi je zra če njem.Jed na gru pa is pi ta ni ka je do bi la od re đe ne smer ni ce od sto ma to lo ga pre le če nja zra če njem, dok dru ga grupa ni je do bi la ni ka kva uput stva.

MATERIJAL I METODE RADA
Za iz vo đe nje studije do bi je na je sa gla snost Etič kog ko mi te ta na dr žav nom Uni ver zi te tu Pa ra i ba (UEPB), gde je pro je kat re gistro van pod bro jem 0039.0.133.000-12.Is pi ta ni ci su da li pi sa ni pri sta nak (TCLE) za uče šće u stu di ji, u skla du s Re zo lu ci jom br.196/96 Mi ni star stva zdra vlja, ko ja re gu li še is tra ži va nja na lju dima (Bra zil, 1996).Svi po da ci do bi je ni od bo le sni ka tre ti ra ni su kao po ver lji vi, či me se šti ti la nji ho va pri vat nost.
Kvan ti ta tiv na, ana li tič ka i stu di ja pre se ka je iz ve de na ko rišće njem po seb nog upit ni ka ko ji se od no si na kva li tet ži vo ta, a ko ji su osmi sli li struč nja ci Uni ver zi te ta u Va šing to nu (Uni ver sity of Was hing ton Qu a lity of Li fe -UWQOL), ver zi ja 4.
Is pi ta ni ke su či ni li obo le li od ma lig nih neo pla zmi u pre de lu gla ve i vra ta ko ji su bi li pod vrg nu ti te ra pi ji zra če njem.U stu di ju je uklju čen 71 bo le snik sa di jag no zom neo pla zme u pre de lu glave i vra ta ko ji je am bu lant no pri mio zrač nu te ra pi ju, bi lo sa mu ili u kom bi na ci ji s hi rur škim le če njem i/ili he mi o te ra pi jom, u Bol ni ci "Na po le ão La u re a no" (HNL) i Fon da ci ji za po moć brazil ske dr ža ve Pa ra i ba (FAP).
Za oda bir bo le sni ka ko ri šće ni su sle de ći kri te ri ju mi: bo le snici oba po la, sta ri ji od 18 go di na ko ji su pri mi li zrač nu te ra pi ju u svrhu le če nja neo pla zme u pre de lu gla ve i vra ta, is klju či vo ili u kom bi na ci ji s ope ra ci jom i/ili he mi o te ra pi jom, i ko ji su za vr ši li pre pi sa nu zrač nu te ra pi ju.
Po da ci su pri ku plja ni od fe bru a ra do no vem bra 2012.go di ne u obe bol ni ce u dr ža vi Pa ra i ba (se ve ro i stok Bra zi la) i uklju čiva li su am bu lant ne bo le sni ke HNL u gra du Žo ao Pe soa (Jo ão Pes soa), kao i am bu lant ne bo le sni ke ko ji su bi li upu će ni na speci jal ni pro gram (SBOn co) na me njen pa ci jen ti ma pod vrg nu tim an ti ne o pla stič noj te ra pi ji u FAP, u okvi ru On ko lo škog cen tra "Dr.Ulis ses Pin to" u gra du Kam pi na Gran de (Cam pi na Gran de), u dr ža vi Pa ra i ba.
Po da ci su pri ku plje ni po mo ću upit ni ka UW-QOL (verzi ja 4) na por tu gal skom je zi ku, ko ji je pri pre mi lo Ode lje nje za oto ri no la rin go lo gi ju, hi rur gi ju gla ve i vra ta Uni ver zi te ta u Va šing to nu 2003.go di ne.Ovaj upit nik je ko ri šćen u mno gim stu di ja ma.Sa sto jao se od 12 pi ta nja o raz li či tim aspek ti ma kva li te ta ži vo ta bo le sni ka: bol, iz gled, ak tiv nost, re kre a ci ja, gu ta nje, žva ka nje, go vor, ra me, ukus, plju vač ka, ras po lo že nje i ank si o znost [7].Sta nje oral nog zdra vlja je pro ce nje no na osno vu Lok hartovih (Loc khart) i Klar ko vih (Clark) kri te ri juma [9], ko ji ma se pro ce nju ju sta nje zu ba, sta nje pa ro don ci juma i hi gi je na usne du plje.Do bi je ni po da ci su sta ti stič ki ob ra đe ni ko ri šće njem R ver zi je soft ve ra 2.15.1 (The R Fo un da tion for Sta ti sti cal Com pu ting, Beč, Austri ja).Ko ri šće ni su Po a so nov (Po is son) mo del li ne ar ne regre si je i mo del lo gi stič ke re gre si je (5% je bio ni vo zna čaj no sti).
S ob zi rom na to da ni je dan bo le snik ni je imao uklo nje ne lim fne žle zde na vra tu, pi ta nje o "ra me nu" je is klju če no iz studi je, či me je osta lo 11 ka te go ri ja od pr vo bit nih 12. Op šti kvali tet ži vo ta bo le sni ka ana li zi ran je sa bi ra njem bo do va sva kog pi ta nja iz upit ni ka, a uku pan re zul tat je bio u ra spo nu od 0 do 1.100.Kom po zit ni re zul tat je ta ko đe iz ra ču nat kao sred nja vred nost svih 11 gru pa, a skor je bio iz me đu 0 i 100 bo do va, gde 0 pred sta vlja naj go ri kva li tet ži vo ta, a 100 naj bo lji.Is pi ta ni ci su to kom is tra ži va nja po de lje ni u dve gru pe: na one ko ji su ima li sto ma to lo ški nad zor i ko ji su kli nič ki pra će ni i na one ko ji ni su.Naj ve ći pro se čan ukup ni re zul tat bio je 830,13, ko ji je do bi jen kod nad gle da nih bo le sni ka, dok je naj ve ći kom bi no va ni re zul tat bio 74,56, ta ko đe kod ovih is pi ta ni ka (Ta be la 2).
Po je di nač na ana li za sva kog odelj ka upit ni ka po ka za la je da je kod bo le sni ka ko ji su nad gle da ni do men s naj ma njim re zulta tom bio "re kre a ci ja" (65,68 bo do va), dok je naj bo lji re zul tat bio za "bol" (93,13 bo do va).U gru pi is pi ta ni ka ko ji ni su ima li sto ma to lo šku kon tro lu do men s naj ma njom sred njom oce nom bio je "plju vač ka" (32,4 bo da), a s naj vi šom ta ko đe "bol" (85 bo do va).
Pro ce na oral nog zdrav stve nog sta nja na osno vu Lok har to vih i Klar ko vih kri te ri ju ma [9], gde su re zul ta ti bi li u ra spo nu od 1 do 5 (pet pred sta vlja naj go re sta nje oral nog zdra vlja), po ka za la je da su bo le sni ci ko ji ni su bi li kli nič ki pra će ni ima li naj ve ći skor (naj go re sta nje) u tri obla sti.U po gle du ka ri je sa, ista gru pa do bi la je oce nu 3,8, što ozna ča va po sto ja nje ka ri je sa ka te gori zo va nog iz me đu "vi dljiv" i "ge ne ra li zo va no op se žan"; sta nje pa ro don ci ju ma do bi lo je re zul tat 3,75, što pred sta vlja mo bil nost u ra spo nu od mi ni mal ne do uz na pre do va le, dok je pro seč na oce na od 4,8 za oral nu hi gi je nu ozna ča va la lo šu hi gi je nu usta i zu ba (Ta be la 3).
Test ko re la ci je iz me đu bo le sni ka ko ji su ima li sto ma to lo šku kon tro lu i onih ko ji ni su po ka zao je sta ti stič ku zna čaj nost u obla sti ma "plju vač ka" (p<0,001) i "pro ble mi to kom se dam da na pre in ter vjua" (p=0,0245).U ko re la ci ji sa so ci o bi o lo ško-de mograf skim od li ka ma, ni jed na va ri ja bla ni je po ka za la sta ti stič ki zna čaj nu ko re la ci ju (p<0,05).

DISKUSIJA
Ova stu di ja je uklju či la 71 bo le sni ka ko ji je le čen zra če njem u pre de lu gla ve i vra ta, me đu ko ji ma je mu ška ra ca bi lo dva i po pu ta vi še ne go že na.Is pi ta ni ci su u pro se ku ima li 62 go di ne, a ve ći na je bi la sta ri ja od 60 go di na i ne kav ka ske ra se.U stu di ji An že la (An ge lo) i sa rad ni ka [7] pro seč na sta rost bo le sni ka bi la je 63,5 go di na (ras pon 40-83 go di ne), mu ška ra ca je bi lo 30 (73,2%), 23 is pi ta ni ka su bi la ne kav ka ske ra se (56,1%) i 19 u bra ku (46,3%).Slič ni na la zi za be le že ni su i u dru gim stu di jama [10,11].
Pro ce na kva li te ta ži vo ta kroz pri me nu upit ni ka UW-QOL je slo žen pro ces ko ji uklju ču je op šta i spe ci fič na pi ta nja u raz li čitim obla sti ma ko je uti ču na ži vot oso ba obo le lih od neo pla zmi gla ve i vra ta.Ana li za je po ka za la da je uku pan re zul tat na ovom upit ni ku ni zak za bo le sni ke ko ji ni su bi li sto ma to lo ški nad zi rani: oko po lo vi ne vred no sti naj ve ćeg mo gu ćeg re zul ta ta -633,4 bo do va, kao i kom po zit ni re zul tat od 57,58.Slič ni re zul ta ti su do bi je ni u stu di ji Li me (Li ma) i sa rad ni ka [12].Bra zil ska stu dija ura đe na u gra du Ku ri ti ba (Cu ri ti ba) [13], ko ja je ob u hva ti la bo le sni ke pod vrg nu te la rin gek to mi ji i gde su svi is pi ta ni ci bi li sto ma to lo ški nad gle da ni i kli nič ki pra će ni, za be le ži la je uku pan re zul tat od 900,25.
Vej mi ler (Weymul ler) i sa rad ni ci [14] u pro spek tiv noj stu di ji na 549 bo le sni ka s neo pla zmom gla ve i vra ta ko ji su pro šli te rapi ju zra če njem po ka za li su da je to kom pr va tri me se ca na kon le če nja re zul tat ko ji me ri kva li tet ži vo ta znat no ni ži.Po bolj ša nje po či nje po sle šest me se ci do jed ne go di ne, ka da se po sti že stabil nost, te do tre će go di ne po sle te ra pi je, ka da bo le sni ci na u če da ži ve s po sle di ca ma le če nja.Da kle, pe ri o di pre i od mah na kon pri me nje ne te ra pi je zra če njem su kri tič ne fa ze, ka da su bo lesni ci vr lo ose tlji vi, a nji hov kva li tet ži vo ta na naj ni žem ni vou.
Na kon ana li ze pro seč nih re zul ta ta iz ra ču na tih za sva ku oblast u okvi ru upit ni ka UW-QOL za obe gru pe, naj go ri re zul ta ti usta no vlje ni su za "plju vač ku", "ukus" i "žva ka nje" kod is pi ta nika ko ji ni su sto ma to lo ški nad gle da ni, što je uti ca lo na ukup nu sred nju oce nu za ovu gru pu bo le sni ka, s ob zi rom na to da su pr ve dve obla sti do bi le naj vi še oce ne u gru pi ko ja je bi la nad zira na i kli nič ki pra će na, dok je za oblast "žva ka nje" re zul tat bio mno go vi ši ne go u pr voj gru pi.
"Žva ka nje" je fak tor ko ji je sma njio kva li tet ži vo ta svo jim re zul ta tom u stu di ja ma Ro džer sa (Ro gers) i sa rad ni ka [16] i An dra da (An dra de) [17] i ko ji se ta ko đe po ka zao re le vant nim u na šoj stu di ji u po sled njih se dam da na pre in ter vju i sa nja is pita ni ka.Slič ni re zul ta ti su do bi je ni i u dru gim is tra ži va nji ma [18,19].Iako is pi ta ni ci na še stu di je ni su ima li zna čaj na ošte će nja kao po sle di cu neo pla zme, fak to ri kao što su "ank si o znost", "izgled" i "ak tiv nost" bi li su zna čaj ni to kom opo rav ka i po vrat ka nor mal nim dru štve nim ak tiv no sti ma [17][18][19][20].
Pri me na Lok har to vih i Klar ko vih kri te ri ju ma [9] do ve la je do re la tiv no vi so ke oce ne, ko je su bi le bli zu mak si mal nih 5, poseb no za fak to re u ve zi s oral nom hi gi je nom, gde je gru pa ko ja ni je bi la sto ma to lo ški kon tro li sa na ima la oce nu 4,08 (oce na 5 ozna ča va naj go ru oral nu hi gi je nu).Vi so ke oce ne su do bi je ne u obe gru pe kod fak to ra ko ji su u ve zi s ka ri je som i pa ro don to pati jom, gde je gru pa ko ja je nad gle da na ima la ne znat no bo lje rezul ta te.Ovi re zul ta ti su bi li slič ni i u stu di ji Go me so ve (Go mes) [21], u ko joj je za pa že no da ve ći na bo le sni ka odr ža va re dov nu hi gi je nu usta i zu ba (41,2%), ima pre ka ri je sne le zi je (35,3%) i zna tan gu bi tak ko šta ne ma se (41,2%), što po ka zu je da oso be obo le le od neo pla zme tre ba da pra ti sto ma to log ne sa mo to kom i na kon zrač ne te ra pi je, već i pre po čet ka le če nja.
Utvr đe na je po zi tiv na ko re la ci ja iz me đu is pi ta ni ka ko ji su sto ma to lo ški nad gle da ni i onih ko ji ni su pre i to kom le če nja zra če njem u ve zi s fak to rom "plju vač ka" (p=7,85 -05 ).Ta ko đe je po tvr đe na po zi tiv na ko re la ci ja iz me đu bo le sni ka ko ji su sto mato lo ški nad zi ra ni i onih ko ji ni su pre i to kom te ra pi je zra če njem u sa mo per cep ci ji oral nog zdrav stve nog sta nja (p=0,0245), zbog či nje ni ce da su is pi ta ni ci ko ji si kon tro li sa ni do bi li in struk ci je ka ko da se bo re pro tiv kse ro sto mi je.Ova ko re la ci ja je ta ko đe utvr đe na u stu di ji Ma ti ja sa i sa rad ni ka [15].Pre ma is tra ži va nju Kil ba sa (Ki el bass) i sa rad ni ka [8], da se spro ve la efi ka sna bor ba pro tiv mu ko zi ti sa, hi po sa li va ci je, tri zmu sa, gu bit ka ose ća ja uku sa, ka ri je sa i oste o ra di o ne kro ze (naj če šće po sle di ce zra če nja u usnoj šu plji ni), ak tiv no i ra no uklju či va nje sto ma to lo ga -ka ko bi se delo va lo pre ven tiv no, ali i te ra pij ski -ve o ma je zna čaj no za po boljša nje kva li te ta ži vo ta bo le sni ka to kom i na kon le če nja zra če njem.
Pri me ću je se da su pa ro don tal ni, kao i sta nje čvr stih zubnih tki va i/ili upo tre ba im plan ta ta, za stu plje ni go to vo u svim ko re la ci ja ma s ni vo i ma zna čaj no sti iz me đu p<2 -16 i p=0,030, jer su di rekt no po ve za ni sa žva ka njem.Da kle, oral no zdravstve no sta nje di rekt no uti če na kva li tet ži vo ta bo le sni ka ko ji su bi li pod vrg nu ti zra če nju gla ve i vra ta, što po tvr đu ju i re zul ta ti stu di je An že la i sa rad ni ka [7], gde je fak tor "žva ka nje" do bio naj ni žu sred nju oce nu od svih ana li zi ra nih obe lež ja, a ta ko đe je bio naj re le vant ni ji fak tor to kom ne de lje pre in ter vjua.Ova či nje ni ca ilu stru je va žnost "žva ka nja" za kva li tet ži vo ta bo le snika i ja sno na gla ša va po tre bu za sto ma to lo škim nad gle da njem i kli nič kim pra će njem u svim fa za ma le če nja neo pla zme [21].

ZAKLJUČAK
Uop šte no go vo re ći, kva li tet ži vo ta svih oso ba obo le lih od neopla zme je po re me ćen, što sa mom neo pla zmom, što pri me njenim me to da ma le če nja.Fak to ri ko ji su naj vi še po go đe ni, a ko ji su va žni za pro ce nu kva li te ta ži vo ta, va ri ra ju iz me đu stu dij skih gru pa i ima ju ve će vred no sti kod bo le sni ka ko ji su sto ma to lo ški nad gle da ni pre, to kom i po sle le če nja zra če njem.S ob zi rom na to da i bo lest i me to de ko je se ko ri ste za le če nje uti ču na kva li tet ži vo ta bo le sni ka i nji ho vih po ro di ca, ne ga zu ba tre ba da poč ne i pre pr ve te ra pi je zra če njem.

Table 3 .
Assessment of dental health according to theLockhart and