Journal Club

PREPARED BY: NIYAS UMMER

Oral Health-Related Quality of Life

of Patients with
Oral Lichen Planus, Oral Leukoplakia, or
Oral Squamous Cell Carcinoma

J KARBACH, B AL-NAWAS, M MOERGEL, M DAUBLANDER

J ORAL MAXILLOFAC SURG 72:1517-1522, 2014

Introduction

Premalignant and Malignant Diseases

Frequently

seen in oral and maxillofacial

surgery
Malignant

transformation rate: 1 to 18 %

Monitoring

by a specialist - strongly recommended

Oral
lichen planus
(OLP)
Malignant
potential
- only histologic

evaluation

Oral leukoplakia (OL)

Oral squamous cell carcinoma
Early detection
(OSCC) - survival and quality of life

Background
Impact

of OLP, OL or OSCC on oral healthrelated quality of life (OHRQoL) seems to

be variable

Consultation of physicians can be delayed

OLP and OHRQoL

High

levels of stress, anxiety, and depression

- etiology of OLP (Chaudhary)

Clinical

management poses considerable

difficulties to oral physician and
dermatologist

Asymptomatic/symptoms

ranging from
burning sensations to severe pain - interfere
with speaking, eating, swallowing

OHRQoL

- chronic character, different clinical

forms, psychological influences, and
difficulties in treatment

OL and OHRQoL
Premalignant
Differential

lesion

diagnosis from OLP - often

difficult
OHRQoL

of patients with OL has been

evaluated in 2 articles

OSCC and OHRQoL

Profiling

of early OSCC

After

treatment, patients have impairment in

OHRQoL, depending on tumor classification and
therapy

To

measure OHRQoL - European Organization for

Research and Treatment of Cancer (EORTC) scale
EORTC

Impact

QLQ-C-30 questionnaire

of OSCC on patients OHRQoL at time of

diagnosis and before treatment of OSCC mentioned only in a small number of articles

Oral Health Impact Profile (OHIP)

Common

questionnaire for measuring

OHRQoL
During

diagnosis and therapy of oral

diseases

Study Methodology

Aims
1)

To measure and compare the OHRQoL of

patients with OLP, OL, and OSCC using
German version of 14-item OHIP (OHIPG14)

2)

To determine whether different clinical

forms of OLP, OL, or OSCC and patients
gender, age, alcohol usage, and smoking
behaviour would have an influence on
OHRQoL before therapy

Materials

Department of Oral Surgery, University Medical

Center, Mainz, Germany in 2010
154 new
patients

Clinical diagnosis of OLP, OL, or OSCC

Examined previously or underwent

therapy

Methods
Informed

verbal and written consent from

each patient

Participants

asked to complete OHIP-G 14

Refusal to Participate

Questionnaire
OHIP-14

(short form) [Slade]

Translated

into German [John et al]

Determine

degree of impact of different oral

diseases on 7 dimensions (2 items per dimension)
OHIP-14 Dimensions

Never

Functional limitation

Barely

Physical pain

Sometimes

Psychological discomfort

Often

Really often

Answered

using
a Likert
scale
Physical
disability

Maximum

Psychological
score
56 (8 disability
in each dimension)

Analysis

subscale

Social disability
of total
score or score for each
Handicap

Categorization of OLP
Andreasen

OHRQoL

(1968)

Reticular
Papular
Plaquelike

Atrophic
Bullous
Ulcerative

scores of patients with

asymptomatic forms were grouped
together and compared with symptomatic
forms

Categorization of OL

Homogenous

Non-homogenous

Inhomogeneous leukoplakia
Erythroleukoplakia
Erythroplakia)

Categorization of OSCC
By

tumor size (greatest dimension) - TNM

classification
T1
T2
T3
T4

2 cm
>2 cm to 4 cm
>4 cm
>4 cm or invades
bone

SPSS 17.0

Statistical Analysis

(SPSS, Inc, Chicago, IL)

Qualitative

variables - absolute and relative

frequencies

Kruskal-Wallis
Univariate
Wilcoxon
Fisher

test

analysis
signed-rank test

exact test

Multivariate
Variable

logistic regression

selection with backward elimination

Outcome with a P value less than .05 significant

Results

Table 2 Gender and Age Distribution

Patients
(n=154)

P Value OLP
(n=73)

OL (n=44)

OSCC
(n=37)

Men

<0.001

22

28

22

51

16

15

60

55

64

Women
Age

0.017

Table 2 Habits Distribution

Patients

P Value

OLP

OL

OSCC

Alcohol

0.040

Never

17

16

<2/wk

40

24

2-4/wk

11

10

OLP

OL

OSCC

68

22

15

22

22

Daily

Patients

P Value

Smoking

<0.001

Non-smoker
Smoker

Inferences
No

influence of age, smoking habits, and

alcohol consumption

Gender

was identified as an influential

factor in patients with OLP (P = .002)

Women

with OLP showed higher scores

than men with OLP

Table 2 Forms of OLP

Erosive; 30%

Reticular; 58%
Atrophic; 10%
Plaque-like; 3%

Reticular
Papular
Plaque-like
Atrophic
Erosive
Bullous

Table 2 Forms of OL

Erythroplakia; 11%
Erythroleukoplakia; 5%
Homogenous
Inhomogenous

Inhomogenous; 18%
Homogenous; 66%

Erythroleukoplaki
a

Table 2 Forms of OSCC

T4; 16%
T3; 3%

T
1
T1; 51%

T2; 30%

T
2

Table 1 - Comparison of OHIP

OHIP-14
Dimensions

P Value
(One-way
ANOVA)

OLP

OL

OSCC

Functional limitation

0.762

0.73

0.66

0.81

Physical pain

0.009

3.12

1.73

2.27

Psychological
discomfort

0.933

2.01

1.91

1.81

Physical disability

0.116

1.15

0.66

0.78

Psychological
disability

0.302

1.03

0.82

1.14

Social disability

0.026

0.68

0.57

1.11

Handicap

0.324

0.70

0.61

0.84

OHIP-14 (all items)

0.86

9.42

6.95

8.81

Table 3 - Comparison of OHIP

P Value
(Wilcoxon
test)

Asymptomat
ic

Symptomat
ic

Functional limitation

0.846

0.66

0.83

Physical pain

0.016

2.84

3.55

Psychological discomfort

0.118

1.59

2.66

0.10

0.86

1.59

Psychological disability

0.081

0.77

1.41

Social disability

0.571

0.5

0.97

Handicap

0.252

0.66

0.76

0.084

7.89

11.76

OHIP-14 Dimensions

Physical disability

OHIP-14 (all items)

Differentiation of OL by clinical form or OSCC by tumor size

showed no difference in OHRQoL

Discussion

Impact of OHRQoL
Did

not differ among 3 groups, except

dimensions physical pain and social
disability

Dimension
OL

physical pain

was influenced very marginally

OSCC

showed an intermediate impact

Highest

scores for OLP

Impact of OHRQoL
Dimension

social disability

OSCC

showed the greatest influence, followed

by OLP

OL

OLP

showed almost no influence

- clinical forms:

Symptomatic

OLP showed a greater impact

Asymptomatic

OLP showed lower impact

HRQoL and OHRQoL

HRQoL

is defined as individuals perception of

their position in life in the context of the
culture and the value system in which they live
and in relation to their goals, expectations,
standards and concerns
(WHO)

OHRQoL

- state of health as patients perceive it

This

perception has to be interpreted by

physician at first visit

Can

help to objectify and quantify the effect of

treatment

OHIP
OHIP

is an established and standardized

instrument for evaluation of OHRQoL

Original

instrument has 49 items

representing 7 domains

Short

form was evaluated by John et al

with 14 items in patients with OLP

Advantages of OHIP
For

evaluation of different oral diseases, in

part without symptoms, OHIP was
preferred to compare OHRQoL of
patients over a longer period

Based on OHRQoL of past month (not past

week)

Suitable for an inhomogeneous group of

patients

Not a specific questionnaire for patients with

cancer

Previous Studies
Llewellyn and Warnakulasuriya
Decrease in OHRQoL in OLP patients
Inhomogeneous group of patients, with smaller number
in each group
Lower OHRQoL in OLP and OL
Lopez-Jornet and Camacho-Alonso
Decrease in OHRQoL in OLP patients
No division into symptomatic or asymptomatic forms
Spanish version OHIP-49 to compare OLP with other oral
diseases (BMS/RAS)
Dimensions physical pain and social disability
showed high values

Inferences
In

this study, patients with symptomatic

OLP recorded physical pain and
physical disability emphasizes need
for physical therapy

Treatment

of symptomatic forms of OLP

into an asymptomatic form - would
improve OHRQoL

Previous Studies

Lundqvist et al
Influence of symptomatic forms of OLP
Decrease of OHRQoL in patients with erosive OLP in
relation to stress (General Perceived Stress
Questionnaire), depression (Beck Depression Inventory),
and state anxiety (State- Trait Anxiety Inventory) was
identified

Inferences Early Detection

Absent

decrease of OHRQoL in dimension

physical pain in asymptomatic forms of
OLP and comparable low influence of OL on
OHRQoL - lower chances of
identification of white lesions - lead to
delays in consulting a physician

Against

the background of potentially

malignant transformation of OL (1 to 18%),
early cancer detection is less likely to occur

Inferences - Malignant Transformation

Confirmation

of dysplasia in OL - regular
examination is the only way to detect a
transformation of the lesion and to
perform a new biopsy examination

Malignant

transformation potential of OLP

- controversial
Jaafari-Ashkavandi

et al - dysplastic and
neoplastic changes in 12% of OLP

Previous Studies Age & Gender

Chen et al
OSCC patients mean age 13 years younger
Larger percentage of males
Wang et al
OSCC patients median age 6 years younger
Male-to-female ratio was similar (1.9:1)
Liu et al
OL patients - Fifth decade of life

Limitations of Study
1.

Not all patients with OSCC exhibited

same tumor size

2.

Influence of tumor localization, lymph

node status, and metastasis on OHRQoL
not evaluated

3.

Bias of the sample, which could affect

the results

Significance of OHRQoL

Statistical differences of impacts among groups

are easy to describe, but clinical importance of
these can be difficult to interpret

Disease management strategies of patients

and clinicians

Critical role in preventing worsening of disease

by adhering to therapeutic regimens

Deciding whether to use health care services

that can enable the detection of malignant
transformation in OL or OLP and OSCC in early
stages

Critical Review

Critical Review
Merits

Demerits

Adequate sample
size

Inconsistent values
of results (Table 2)

Extensive statistical
analysis

Brief review of
literature

Good discussion

Thank You
QUESTIONS?

Suggestions
OHIP-14

questionnaire in our Department

Few simple questions

Easy to answer
Local language
Multidimensional

All oral mucosal diseases

TMJ disorders
Orofacial Pain
Complications of pulpal pathology

First visit
Recall visits
Relationship between oral health and general well being
Follow up of treatments/conditions
Record keeping for statistical surveys

OHIP-14 Questionnaire