Search

This clinical report describes the successful prosthetic rehabilitation of a deficient lower lip in an edentulous patient who had undergone surgery for removal of a squamous cell carcinoma of the anterior floor of the mouth and vestibule. The rehabilitation used a combined approach of an extraoral lip prosthesis joined by 3 magnets to an intraoral implant-retained mandibular resection prosthesis. The outcome demonstrated rehabilitation of the lower third of the face by eliminating loss of fluids and by improving the facial profile, lip contour and competence, esthetics, the patient's eating ability, speech intelligibility, and reported quality of life.

Custom intraoral radiation devices protect normal tissues, minimizing the adverse effects of radiation therapy. These devices also help immobilize the target by placing the patient's head in a precise, repeatable position. This clinical report describes the fabrication and benefits of a modified mouth opening, tongue depressing radiation stent with bilabial protrusion of the lips that was used in proton radiation therapy for a malignancy of the upper lip.

PURPOSE: We aim to characterize the quantitative dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) parameters associated with advanced mandibular osteoradionecrosis (ORN) compared with the contralateral normal mandible. METHODS AND MATERIALS: Patients with a diagnosis of advanced ORN after curative-intent radiation treatment of head and neck cancer were prospectively enrolled after institutional review board approval and study-specific informed consent were obtained. Quantitative maps generated with the Tofts and extended Tofts pharmacokinetic models were used for analysis. Manual segmentation of advanced ORN 3-dimensional volume was done using anatomic sequences to create ORN volumes of interest (VOIs). Subsequently, normal mandibular VOIs were segmented on the contralateral healthy mandible of similar volume and anatomic location to create control VOIs. Finally, anatomic sequences were coregistered to DCE sequences, and contours were propagated to the respective parameter maps. RESULTS: Thirty patients were included. The median time to ORN diagnosis after completion of IMRT was 38 months (range, 6–184 months), whereas median time to ORN progression to advanced grade after initial diagnosis was 5.6 months (range, 0–128 months). There were statistically significant higher K(trans) and V(e) in ORN-VOIs compared with controls (0.23 vs 0.07 min(−)(1), and 0.34 vs 0.15; P

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

PURPOSE/OBJECTIVE(S) Low and middle-income countries (LMICs) are significantly under-represented in cancer research due to a lack of research capacity rooted in historical inequalities. Training in-country physicians in clinical research is one of the most sustainable ways to address the shortage of research in LMICs. As part of an academic partnership between MD Anderson Cancer Center in Houston, TX (MDA) and Cancer Diseases Hospital in Lusaka, Zambia (CDH), an international virtual clinical research course for clinical oncology fellows at CDH was piloted in Fall 2020 to address a significant need for a structured clinical research curriculum. MATERIALS/METHODS The virtual clinical research course took place from August to November 2020 and involved 14 weekly hour-long lectures (13 by MDA faculty, one by CDH faculty) on topics including identifying a research question, study design, clinical trials, research ethics, biostatistics, and scientific writing. The course was attended by 15 clinical oncology fellows. Eight senior fellows were paired with a longitudinal MDA and CDH faculty member and MDA resident/fellow mentor in their area of interest to support a research protocol. Anonymized pre- and post-course surveys were administered with 5-point Likert scale academic self-efficacy inventories and open-ended qualitative questions. Descriptive statistics were used to summarize the findings. RESULTS A total of 12/15 participants (80%) completed the pre-course survey and 11/15 (73%) completed the post-course survey. Average scores pre- and post-course, respectively, for research interest and motivation (5.0, 4.9), comfort reading and evaluating medical literature (3.7, 4.5), developing a study question and design (2.8, 4.0), collecting and managing data (3.3, 4.0), independently performing and publishing research (2.3, 3.7), and satisfaction with mentorship and profession (3.0, 4.2) demonstrated an increase across multiple domains. As of December 2020, there were eight active research proposals led by CDH clinical oncology fellows and there had been 21 meetings and 27 hours of MDA-CDH mentorship time. Positive themes from open-ended feedback included clear lectures, meaningful relationships with mentors, and utility of presenting research proposals for feedback while constructive themes included desire for more teaching on statistical analysis and incorporation of self-assessment modules. CONCLUSION Clinical research is essential to develop effective, evidence-based interventions to the unique cancer care challenges that occur in LMICs. The results from the pilot virtual MDA-CDH research course, which led to improvements in academic self-efficacy scores, support for research proposals led by CDH clinical oncology fellows, and formation of longitudinal mentorship groups demonstrate the feasibility of conducting a virtual longitudinal research workshop model. Continued collaboration and future follow-up will be needed to demonstrate effectiveness and impact.

This report describes the treatment of a 68-year-old man with basosquamous cell carcinoma of the left auricular area. His oncologic treatment resulted in the loss of his left ear and much of the left temporal bone. The loss of a significant portion of the temporal bone precluded the use of extraoral implants. Owing to the lack of anatomic landmarks after his surgical treatment, positioning his auricular prosthesis proved challenging. The fabrication of his prosthesis and a custom positioning aid are described.

Background Patients with metastatic breast cancer may develop oral morbidities that result from therapeutic interventions. Mammalian target of rapamycin (mTOR) inhibitor–associated stomatitis (mIAS) is a common adverse event (AE), secondary to mTOR inhibitor therapy, that can have a negative impact on treatment adherence, quality of life, and health care costs. A multidisciplinary team approach is important to minimize mIAS and to maximize treatment benefits to patients with breast cancer. In this review, we discuss the pathophysiology, diagnosis, and natural history of mIAS. Current and new management strategies for the prevention and treatment of mIAS are described in the context of fostering a coordinated team care approach to optimizing patient care. Types of Studies Reviewed The authors conducted a PubMed search from 2007 through 2017 using the terms "stomatitis," "mIAS," "everolimus," "mTOR," "metastatic breast cancer," and "oral care." They selected articles published in peer-reviewed journals that reported controlled trials and evidence-based guidelines. Results mIAS can be distinguished from mucositis caused by cytotoxic chemotherapy or radiotherapy on the basis of cause, clinical presentation, and treatment paradigms. Specific preventive and therapeutic management strategies can be implemented across the continuum of patient oral health care. Practical Implications Oral health care providers are on the frontline of oral health care for patients with metastatic breast cancer and are uniquely positioned to provide patient education, advocate accurate reporting of mIAS, and support early identification, monitoring, and prompt intervention to mitigate the severity and duration of this manageable, potentially dose-limiting AE.

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

Oral fungal infections present with atypical and varied manifestations, and distinguishing them from other entities including leukemic infiltration can be diagnostically challenging. In this report, we describe a 62 year old female with acute myeloid leukemia who presented, towards the end of her second treatment cycle of decitabine in a prolonged neutropenic state, with a month of painful, necrotic-appearing marginal gingival lesions. She was duly initiated on empiric broad spectrum antifungal treatment but did not show a clinical response with the appearance of new skin lesions concerning for progressive fungemia. Concurrent gingival and cutaneous biopsy showed fungal invasion with Fusarium. Despite changing antifungal treatment the lesions progressed, and white blood cell (WBC) transfusions were instituted. The patient had an impressive response with gradual resolution of the skin lesions and regression in gingival lesions over a week of therapy. This case illustrates the highly atypical, confounding appearance of oral fungal infections in immunocompromised hematological malignancy patients. Maxillary and mandibular marginal gingival involvement, although extremely rare, should be recognized as potential sites of fungal involvement. Accurate diagnosis entails a biopsy especially in ambiguous clinical scenarios, as presented here. The role of WBC transfusions in the management of these rare fungal pathogenic infections needs to re-established.

PURPOSE/OBJECTIVE(S) Xerostomia is a common sequela of radiation therapy (RT) and chemoradiotherapy (CRT). Head and neck cancer treatment can contribute to salivary glands injury with diminished salivary production and changes in consistency, volume, and pH of saliva. Previous studies examining xerostomia have investigated RT regimens, dosimetric predictors, and quality of life (QoL) associations but few have identified clinicodemographic risk factors for xerostomia and quantified their associations among oropharyngeal carcinoma (OPC) survivors. The objective of this study was to identify risk factors for xerostomia among long-term OPC survivors. MATERIALS/METHODS This was a cross-sectional study conducted at a comprehensive cancer center. Study participants included disease-free, adult OPC survivors who completed curative definitive radiotherapy treatment between January 2000 and December 2013, and responded to a survey administered from September 2015 to July 2016. This study included 881 OPC survivors with a median survival duration at time of survey of 7 years (range, 1-16 years) of which self-reported xerostomia scores were available for 853 participants. The primary outcome variable was patient-reported xerostomia measured using the MD Anderson Symptom Inventory Head and Neck Cancer Module. Clinicodemographic risk factors for moderate to severe xerostomia were identified using multivariable logistic regression. RESULTS Of 853 OPC survivors who responded to the xerostomia question, 337 (39.5%) reported moderate to severe xerostomia. Multivariable logistic regression identified current smoking at time of survey (OR:2.57, 95% CI: 1.20-5.53, P = 0.016) as a risk factor for moderate to severe xerostomia and concurrent cetuximab chemotherapy (OR:0.63; 95% CI: 0.41-0.97, P = 0.038) as a protective factor. Additionally, female sex (OR:1.81, 95% CI: 1.21-2.71, P = 0.004) and less than high school education (OR:1.68, 95% CI: 1.15-2.45, P = 0.008) were risk factors for moderate to severe xerostomia and bilateral intensity modulated radiotherapy (IMRT) combined with proton therapy (OR:0.34, 95% CI: 1.16-0.73, P = 0.005) and ipsilateral IMRT (OR:0.18, 95% CI: 0.07-0.46, P < 0.001) were protective. CONCLUSION In this large xerostomia study, about 4 out of 10 OPC survivors reported moderate to severe xerostomia over long-term follow-up. Continued smoking after cancer diagnosis, sex, and education were identified as important risk factors of moderate to severe xerostomia and concurrent cetuximab therapy and more modern RT regimens had a protective association. Sustained smoking post-diagnosis is a modifiable risk factor which can be addressed with continued smoking cessation efforts. Lastly, these results can inform future research and targeted patient-centered interventions to monitor and manage RT-associated xerostomia and preserve QoL among OPC patients.

To determine dosimetric parameters associated with osteoradionecrosis (ORN) in oropharyngeal cancer (OPC) patients in the IMRT era.Subsequent to institutional review board approval, we identified ORN in OPC patients treated with IMRT from 2002 to 2013. 1:2 case-control matching was implemented. Mandibular dose-volume histograms (DVH) were extracted. Dosimetric parameters were compared using non-parametric stats. Recursive partitioning analysis (RPA) was done to identify DVH correlates of ORN.68 ORN cases and 131 controls were matched. Median follow-up was 41months and median time to development of ORN was 16months. Mandibular mean dose was significantly higher in the ORN cohort (48.1 vs 43.6Gy, p0.0001). However, the maximum dose was not statistically different. DVH bins from V35 to V73 were all significantly higher in the ORN cohort compared with controls (p0.0006). Two DVH parameters were identified in RPA analysis, V43 and V58. The majority (81%) of ORN cases were observed with both V44≥42% and V58≥25%.Our data demonstrate that a wide range of DVH parameters in the intermediate and high beam path were all significantly higher in ORN patients. Mandibular V4442% and V5825% represent reasonable DVH constraints for IMRT plan acceptability, when tumor coverage is not compromised.

Understanding the growth rates of fish is vital for effective fisheries management. Historically a three-parameter von Bertalanffy growth model (VBGM) has most often been used to describe the somatic growth of fish. However, increasingly, populations are identified with patterns of growth that are not adequately described by the standard VBGM. We describe a more flexible growth model obtained by replacing the normally constant von Bertalanffy growth coefficient, k, with a piecewise constant function, K, of age. In principle this allows arbitrary monotonic growth to be approximated within a generalized von Bertalanffy structure. Posterior distributions of model parameters are approximated by the method of Hamiltonian Monte Carlo using the Stan software package. Spline smoothing of the K function is achieved by specifying a hierarchical random walk prior. We compare fits achieved using this new approach to observations of length-at-age of southern bluefin tuna (Thunnus maccoyii) with a range of existing growth models.

The purpose is to examine the relationship between mandibular osteoradionecrosis (ORN) and chronic dysphagia in long-term oropharynx cancer (OPC) survivors, and to determine the perceived symptom burden associated with ORN.Medical records of 349 OPC patients treated with bilateral IMRT and systemic therapy were reviewed. ORN was graded using a published 4-point classification schema. Patients were considered to have chronic dysphagia if they had aspiration pneumonia, stricture or aspiration detected by fluoroscopy or endoscopy, and/or feeding tube dependence in long-term follow-up ⩾1year following radiotherapy. MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) scores were analyzed in a nested cross-sectional survey sample of 118 patients.34 (9.7%, 95% CI: 6.8-13.3%) patients developed ORN and 45 (12.9%, 95% CI: 9.6-16.9%) patients developed chronic dysphagia. Prevalence of chronic dysphagia was significantly higher in ORN cases (12/34, 35%) compared to those who did not develop ORN (33/315, 11%, p0.001). ORN grade was also significantly associated with prevalence of dysphagia (p0.001); the majority of patients with grade 4 ORN requiring major surgery (6 patients, 75%) were found to have chronic dysphagia. Summary MDASI-HN symptom scores did not significantly differ by ORN grade. Significantly higher symptom burden was reported, however, among ORN cases compared to those without ORN for MDASI-HN swallowing (p=0.033), problems with teeth and/or gums (p=0.016) and change in activity (p=0.015) item scores.ORN is associated with excess burden of chronic dysphagia and higher symptom severity related to swallowing, dentition and activity limitations.

This clinical report describes the fabrication of an implant-supported and magnet-retained combination oral-nasal prosthesis for a patient with a midline midfacial defect. The patient had undergone a total rhinectomy and partial maxillectomy as part of his cancer treatment. The nasal prosthesis was retained on the face by a magnet attached to the implant-supported maxillary denture, resulting in improved appearance and the recovery of speech, mastication, and swallowing functions.

Delamination of the maxillofacial silicone elastomer away from the commercially pure titanium (cpTi)-encapsulated magnets affects the long-term performance of the facial restoration.The purposes of this in vitro study were to investigate the interfacial microleakage patterns of 2 maxillofacial silicone elastomers with cpTi when 3 different primers were used and to evaluate the porosity of the 2 elastomers tested.To test the interfacial microleakage patterns of the 2 elastomers MDX4-4210 (EL1) and A-2006 (EL2) with cpTi when 3 metal primers, A-304 (PR1), A-320 bonding enhancer (PR2), Super-Bond CB monomer (PR3), and ethyl-cyanoacrylate (Super Glue) were used, the bonded interfaces were observed using reflected light microscopy, and the percentage of the linear extent of leakage along the interface (%microleakage) was measured. High-resolution x-ray computed microtomography scanning was used to investigate the percentage of void volume fraction (%VF) for both silicone EL1 and EL2. The data were analyzed with 2-way ANOVA and post hoc tests (α=.05).No statistically significant differences were found among the percentages of PR1, PR2, and PR3 microleakage, whereas ethyl-cyanoacrylate showed a statistically significant higher percentage of microleakage than either of the silicone elastomers (P.001). EL1 medical grade elastomer groups have always had a statistically significantly higher percentage of microleakage than the EL2 platinum silicone elastomer groups (P.001). For both elastomers, no statistically significant differences were found in %VF (P=.056).Differences in mechanical properties, chemical composition, and manipulations during handling of the maxillofacial silicone elastomers can affect the linear microleakage along the cpTi-silicone elastomer bonding interface and the porosity of the silicone elastomer.

Objectives To investigate the effect of three adhesive primers on the morphology, chemistry and peel bond strength of two maxillofacial silicone elastomers with commercially pure titanium (cpTi). Methods The effect of three primers (PR2:A-304 Primer/A-320 Bonding Enhancer, PR3:Super Bond, and PR4:Super Glue) on cpTi morphology and chemistry were studied by reflected light polarized microscopy (RPOLM) and reflection Fourier-transform infrared microspectroscopy (RFTIRM). For testing the bond strength between two elastomers (EL1:MDX4-4210, EL2:A-2006) and primed cpTi surfaces, a 90° T peel test was performed (PBS), using as reference EL1, EL2 specimens bonded to heat-cured poly(methyl methacrylate) resin (PMMA) primed with A-330G primer (PR1). Failure modes were analyzed under a stereomicroscope, and the percentage of remaining silicone (RS%) on cpTi and PMMA were calculated by image analysis. Scanning electron microscopy/energy dispersive X-ray spectrometry (SEM/EDX) was used to investigate representative failure patterns on cpTi. Data were analyzed with Weibull analysis, ANOVA plus post hoc tests, and Pearson correlation coefficient ( a = 0.05). Results Thick-irregular (PR2), thin-smooth (PR3), and uniform-porous (PR4) films were identified on cpTi by RPOLM. RFTIRM revealed: a strong peak of Si–O–Si with a distribution following the outline of the image (PR2); COO-M groups developed, but unevenly distributed (PR3); and reduction in C C groups due to in situ polymerization (PR4). Following PBS, the ranking of the statistical significant differences in Weibull scale parameter ( σ 0 ) of the EL1 group was PMMA_PR1 > cpTi_PR2,cpTi_PR3 > cpTi_PR4, whereas for the EL2 group cpTi_PR2 > PMMA_PR1 > cpTi_PR4,cpTi_PR3. For RS%, the ranking in the EL1 group was: PMMA_PR1 > cpTi_PR2 > cpTi_PR3 > cpTi_PR4, and in the EL2 cpTi_PR2 > cpTi_PR3 > cpTi_PR4,PMMA_PR1. There was no statistically significant correlation between PBS and RS%, with the exception of EL1_PMMA_PR1. In all groups mixed failure modes were found by SEM/EDX. Significance Although there is evidence of bonding with cpTi, there are important differences among the primer/elastomer combination that may affect the clinical performance of these materials.

Customized intraoral devices help the radiation oncologist minimize the adverse effects of radiation and maximize the tumor control rate by keeping the anatomic structures in a consistent position during each fraction of radiation treatment. This article illustrates the fabrication of a bolus-type positioning device for a combined intraoral/extraoral defect treated with proton radiation therapy.

Background and purpose Customized mouth-opening-tongue-depressing-stents (MOTDs) may reduce toxicity in patients with head and neck cancers (HNC) receiving radiotherapy (RT). However, making MOTDs requires substantial resources, which limits their utilization. Previously, we described a workflow for fabricating customized 3D-printed MOTDs. This study reports the results of a prospective trial testing the non-inferiority of 3D-printed to standard and commercially-available (TruGuard) MOTDs as measured by patient reported outcomes (PROs). Materials and methods PROs were collected at 3 time points: (t1) simulation, (t2) prior to RT, (t3) between fractions 15–25 of RT. Study participants received a 3D-printed MOTDs (t1, t2, t3), a wax-pattern (t1), an acrylic-MOTDs (t2, t3) and an optional TruGuard (t1, t2, t3). Patients inserted the stents for 5–10 min and completed a PRO-questionnaire covering ease-of-insertion and removal, gagging, jaw-pain, roughness and stability. Inter-incisal opening and tongue-displacement were recorded. With 39 patients, we estimated 90% power to detect a non-inferiority margin of 2 at a significance level of 0.025. Matched pairs and t-test were used for statistics. Results 41 patients were evaluable. The 3D-printed MOTDs achieved a significantly better overall PRO score compared to the wax-stent (p = 0.0007) and standard-stent (p = 0.0002), but was not significantly different from the TruGuard (p = 0.41). There was no difference between 3D-printed and standard MOTDs in terms of inter-incisal opening (p = 0.4) and position reproducibility (p = 0.98). The average 3D-printed MOTDs turn-around time was 8 vs 48 h for the standard-stent. Conclusions 3D-printed stents demonstrated non-inferior PROs compared to TruGuard and standard-stents. Our 3D-printing process may expand utilization of MOTDs.

Double tagging studies are used to estimate the proportion of originally tagged fish that shed their tags prior to recapture, but models typically fitted to double tag recoveries have been subject to restrictive assumptions. For example, a common assumption is that the shedding rates of all tags are identical. Hearn et al. (Hearn, W.S., Leigh, G.M., Beverton, R.J.H., 1991. ICES J. Mar. Sci. 48, 41–51) found differences in shedding rates between taggers, and demonstrated algebraically that such differences lead to biases in estimators of shedding rates. However, widely applicable models that account for differences in shedding rates between taggers have not been developed. We adapt the proportional hazards model to the problem of estimating tag shedding rates from double-tag recovery data. Differences in shedding rates between taggers are modelled using multiplicative random effects or frailties. The frailty models are fitted to recoveries from a 1990s tagging study of southern bluefin tuna ( Thunnus maccoyii ) at exact times-at-liberty and the results compared with models previously applied for this species.

Tracheoesophageal (TE) speech using a voice prosthesis and hands-free speaking valve with an intraluminal attachment is the gold standard for voice restoration after total laryngectomy. Modification of a standard self-retaining silicone cannula or laryngectomy button often aids in the attachment of a speaking valve within the tracheal lumen for hands-free TE speech production. An increased number of laryngectomized individuals are able to achieve hands-free TE speech when the standard length, flange, and diameter of a silicone button is customized to accommodate individual tracheostomal contours. A technique is presented for modification of a standard silicone laryngectomy button to facilitate hands-free TE speech after total laryngectomy. (J Prosthet Dent 2009;102:328-331)

Purpose The present study was undertaken to evaluate our recent experience with mandibular osteoradionecrosis (ORN) and to identify factors that contribute to its progress. Patients and Methods The medical records of 114 patients who had been treated for ORN during a 16-year period (1989 to 2004) were reviewed. The patients were then divided into 2 groups according to their response to conservative treatment. Group 1 consisted of patients whose ORN resolved with conservative treatment (n = 47). Group 2 consisted of patients whose ORN was unresolved with conservative treatment or who had required radical resection of the involved tissue (n = 67). The information was obtained from the medical records of the patients and analyzed. Results The patients whose ORN was associated with an early-stage tumor or preirradiation extraction had a favorable response to conservative treatment. However, those who had an advanced primary tumor, had continued smoking and drinking after radiotherapy, had received palliative radiotherapy or a radiation dose of more than 6,000 rads, and who had an orocutaneous fistula, a pathologic fracture, swelling, or trismus had a poor response to conservative treatment. In these latter cases, radical resection of the involved tissue proved useful. Conclusions The results of the present study have indicated that several factors (ie, the stage of the primary tumor, signs of ORN) can influence the progress of ORN. Our results suggest that radical resection is a useful method for treating mandibular ORN that does not respond to conservative treatment.

Purpose To compare the M. D. Anderson Symptom Inventory–Head and Neck (MDASI-HN) module, a symptom burden instrument, with the Functional Assessment of Cancer Therapy–Head and Neck (FACT-HN) module, a quality-of-life instrument, for the assessment of mucositis in patients with head-and-neck cancer treated with radiotherapy and to identify the most distressing symptoms from the patient's perspective. Methods and Materials Consecutive patients with head-and-neck cancer ( n = 134) completed the MDASI-HN and FACT-HN before radiotherapy (time 1) and after 6 weeks of radiotherapy or chemoradiotherapy (time 2). The mean global and subscale scores for each instrument were compared with the objective mucositis scores determined from the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0. Results The global and subscale scores for each instrument showed highly significant changes from time 1 to time 2 and a significant correlation with the objective mucositis scores at time 2. Only the MDASI scores, however, were significant predictors of objective Common Terminology Criteria for Adverse Events mucositis scores on multivariate regression analysis (standardized regression coefficient, 0.355 for the global score and 0.310 for the head-and-neck cancer-specific score). Most of the moderate and severe symptoms associated with mucositis as identified on the MDASI-HN are not present on the FACT-HN. Conclusion Both the MDASI-HN and FACT-HN modules can predict the mucositis scores. However, the MDASI-HN, a symptom burden instrument, was more closely associated with the severity of radiation-induced mucositis than the FACT-HN on multivariate regression analysis. This greater association was most likely related to the inclusion of a greater number of face-valid mucositis-related items in the MDASI-HN compared with the FACT-HN.

Purpose: To study the efficacy and safety of cevimeline in two double-blind trials (Studies 003 and 004) enrolling patients with head and neck cancer in whom xerostomia developed after radiotherapy. Methods and Materials: Subjects were randomly assigned to receive cevimeline, 30 mg three times daily, or placebo for 12 weeks, with the possibility of dose escalation to 45 mg three times daily at 6 weeks. The primary efficacy endpoint was the patient's final global evaluation of oral dryness; change in unstimulated salivary flow was a secondary endpoint. Results: Five hundred seventy subjects (284 in Study 003 and 286 in Study 004) were randomized. Significantly more cevimeline-treated subjects than placebo recipients (47.4% vs. 33.3%, p = 0.0162) in Study 003 reported improvement in dry mouth in the final global evaluation of oral dryness. No significant difference between groups in the final global evaluation was seen in Study 004, in which a high placebo response rate of 47.6% was observed. In both studies, cevimeline-treated subjects had significantly greater increases in the objective measure of unstimulated salivary flow than placebo recipients (p 0.0093 [Study 003] and p = 0.0215 [Study 004]), whereas no significant differences in stimulated salivary flow were observed. The mostmore » frequent adverse event was increased sweating. Conclusion: Cevimeline was well tolerated by patients with xerostomia after radiotherapy for head and neck cancer, and oral administration of 30-45 mg of cevimeline three times daily increased unstimulated salivary flow.« less

To study the risk, outcomes, and costs of radiation-induced oral mucositis (OM) among patients receiving radiotherapy (RT) to head and neck primary cancers.A retrospective cohort consisting of 204 consecutive head-and-neck cancer patients who received RT with or without chemotherapy during 2002 was formed; their records were reviewed for clinical and resource use information. Patients who had received prior therapy, had second primary cancers, or received palliative radiation therapy were excluded. The risk of OM was analyzed by multiple variable logistic regression. The cost of care was computed from the provider's perspective in 2006 U.S. dollars and compared among patients with and without OM.Oral mucositis occurred in 91% of patients; in 66% it was severe (Grade 3-4). Oral mucositis was more common among patients with oral cavity or oropharynx primaries (odds ratio [OR], 44.5; 95% confidence interval [CI], 5.2 to100; p0.001), those who received chemotherapy (OR = 7.8; 95% CI, 1.5-41.6; p = 0.02), and those who were treated with altered fractionation schedules (OR = 6.3; 95% CI, 1.1-35.1; p = 0.03). Patients with OM were significantly more likely to have severe pain (54% vs. 6%; p0.001) and a weight loss ofor =5% (60% vs. 17%; p0.001). Oral mucositis was associated with an incremental cost of $1700-$6000, depending on the grade.Head-and-neck RT causes OM in virtually all patients. Oral mucositis is associated with severe pain, significant weight loss, increased resource use, and excess cost. Preventive strategies are needed.

Purpose: Computed tomography (CT) streak artifacts caused by metallic implants remain a challenge for the automatic processing of image data. The impact of metal artifacts in the soft-tissue region is magnified in cone-beam CT (CBCT), because the soft-tissue contrast is usually lower in CBCT images. The goal of this study was to develop an effective offline processing technique to minimize the effect. Methods and Materials: The geometry calibration cue of the CBCT system was used to track the position of the metal object in projection views. The three-dimensional (3D) representation of the object can be established from only two user-selected viewing angles. The position of the shadowed region in other views can be tracked by projecting the 3D coordinates of the object. Automatic image segmentation was used followed by a Laplacian diffusion method to replace the pixels inside the metal object with the boundary pixels. The modified projection data were then used to reconstruct a new CBCT image. The procedure was tested in phantoms, prostate cancer patients with implanted gold markers and metal prosthesis, and a head-and-neck patient with dental amalgam in the teeth. Results: Both phantom and patient studies demonstrated that the procedure was able to minimize the metal artifacts. Soft-tissue visibility was improved near or away from the metal object. The processing time was 1–2 s per projection. Conclusion: We have implemented an effective metal artifact-suppressing algorithm to improve the quality of CBCT images.

We developed an efficacious and non-irritant mouthwash that is alcohol-free and that has a low concentration of chlorhexidine, in order to be used for preventing oral cavity infections in immunocompromised and cancer patients. The novel mouthwash solution was tested for its antimicrobial efficacy against both free floating (planktonic) and the biofilm forms of Candida albicans. The solution was also tested against Klebsiella pneumoniae, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA), using a modification of a previously published method. The activity of the novel mouthwash was also compared with that of three commercially available mouthwashes. The experimental mouthwash showed efficacy against C. albicans, both in free-floating form and in biofilm. With higher concentration of chlorhexidine, the solution was also efficacious in inhibiting the growth of K. pneumoniae, P. aeruginosa, and MRSA. The antiseptic activity of the alcohol-free mouthwash against other bacterial organisms and C. albicans was comparable to other commercially available alcohol-based mouthwash solutions. A novel alcohol-free mouthwash solution, that has low concentration of chlorhexidine, showed antiseptic effect against planktonic and biofilm forms of C. albicans and against K. pneumoniae, P. aeruginosa, and MRSA.

Radiation-induced xerostomia can result in the rapid onset and progression of dental caries in head and neck cancer patients. Topically applied fluorides have been successfully used to inhibit the formation of dental caries in this population. However, because intensive daily self-application is required, compliance is an issue. The intraoral fluoride-releasing system (IFRS) containing a sodium fluoride core is a newly developed, sustained-release, passive drug delivery system that does not require patient involvement except for periodic replacement, thus reducing the effect of patient compliance on its effectiveness in dental caries prevention. Twenty-two head and neck cancer patients from U. T. M. D. Anderson Cancer Center, with radiation-induced xerostomia, were entered into a pilot study to contrast the daily home use of a 0.4% stannous fluoride-gel-containing tray (control group) to IFRS (study group) with respect to tolerability and adherence, and to obtain information on relative caries preventive efficacy. Participants were stratified on the basis of radiation exposure and randomly assigned to treatment with either IFRS or stannous fluoride gel. Patients in both groups were fitted with two IFRS retainers and also were instructed to use a 1100-ppm fluoride conventional sodium fluoride dentifrice twice daily. The study was conducted as a single-blinded, parallel-cell trial. Pre-existing carious lesions were restored prior to the beginning of the study. The efficacy variable was determined by the mean number of new or recurrent decayed surfaces. Patients were examined for caries 4, 8, 12, 24, 36, and 48 weeks after initiation of treatment. Reports of adverse reactions were based on information volunteered by patients and that were elicited during interviews. At baseline, the resting and stimulated salivary flow rates (g/5min) were significantly greater in the control group than in the study group (p

Radiation-induced xerostomia results in significant changes in the oral cavity particularly oral microbial changes, which include a marked increase in the number of cariogenic organisms, notably Streptococcus mutans and lactobacillus species. This loss of the capacity to secrete saliva creates or promotes the rapid onset and progression of rampant dental caries. In this 2-part series, the benefit of fluoride in reducing caries activity is presented. Part 1 discusses the historical and currently available fluoride preparations and Part 2 presents data of a recently completed trial investigating the benefit of an intraoral sodium fluoride releasing system.

Sarcomas of the head and neck are rare tumors derived from cells of mesenchymal origin. This article briefly discusses the epidemiology, etiology, and classification of head and neck sarcomas. Emphasis is placed on myofibrosarcoma, a malignant tumor of the myofibroblasts. Histologic criteria, prognostic factors, and the multidisciplinary management of these tumors are reviewed. A situation of a surgically excised myofibrosarcoma of the buccal mucosa is reported. In this patient, a stent was fabricated to stabilize a split-thickness skin graft used for the buccal mucosa reconstruction.

Purpose: To analyze three-dimensional setup uncertainties for multiple regions of interest (ROIs) in head-and-neck region. Methods and Materials: In-room computed tomography (CT) scans were acquired using a CT-on-rails system for 14 patients. Three separate bony ROIs were defined: C2 and C6 vertebral bodies and the palatine process of the maxilla. Translational shifts of 3 ROIs were calculated relative to the marked isocenter on the immobilization mask. Results: The shifts for all 3 ROIs were highly correlated. However, noticeable differences on the order of 2–6 mm existed between any 2 ROIs, indicating the flexibility and/or rotational effect in the head-and-neck region. The palatine process of the maxilla had the smallest right-left shifts because of the tight lateral fit in the face mask, but the largest superior-inferior movement because of in-plane rotation and variations in jaw positions. The neck region (C6) had the largest right-left shifts. The positioning mouthpiece was found effective in reducing variations in the superior-inferior direction. There was no statistically significant improvement for using the S-board (8 out of 14 patients) vs. the short face mask. Conclusions: We found variability in setup corrections for different regions of head-and-neck anatomy. These relative positional variations should be considered when making setup corrections or designing treatment margins.

Statement of problem The color instability and degradation of maxillofacial elastomers limit the function and cosmetic quality of facial prostheses. Purpose The purpose of this study was to measure the interactions of oil pigments plus dry earth opacifiers at 5%, 10%, and 15% by volume in stabilizing the color of MDX4-4210/type A silicone elastomers before and after artificial aging. Material and methods In the first part of the study, each of 5 opacifiers (Georgia kaolin powder neutral, kaolin powder calcined, Artskin white, dry pigment titanium (Ti) white, or Ti white artists' oil color) at 10% concentrations were combined with each of 5 oil pigment types (no pigment, cadmium-barium red deep, yellow ochre, burnt sienna, or a mixture of the 3 pigments), for a total of 25 experimental groups of elastomers. In the second part of the study, 50 experimental groups of elastomers were made by combining 1 of 5 opacifiers at 5% and 15% concentrations with 1 of 5 oil pigments as in Part 1. Five specimens of each elastomer were tested, for a total of 375 specimens. In each part of the study, all specimens were aged in an artificial aging chamber. CIE L ∗ a ∗ b ∗ values were measured by a spectrophotometer. The color differences (ΔE ∗ ) were subjected to repeated-measures analysis of variance. Mean values were compared by Tukey-Kramer intervals (α=.05). Results In Part 1, when the opacifiers were tested at 10% concentration, Ti white oil color had the most color change, and dry pigment Ti white had the least; all other opacifiers were not significantly different from each other. In Part 2, at 5%, Ti white oil color had the most color change; all other opacifiers were not significantly different from the others. At 15%, Ti white oil color again had the most color change, followed by Artskin white, kaolin powder calcined, and Georgia kaolin; Ti white dry earth pigment had the least color change. Overall, 5% Artskin white had less color change than the 15%, whereas 15% dry pigment Ti white had less color change than the 5% ( P Conclusions At all 3 concentrations, oil pigments mixed with opacifiers helped protect the MDX4-4210/type A silicone elastomer from color degradation over time. Dry pigment Ti white remained the most color stable over time, followed by the pigments mixed with kaolin powder calcined, Georgia kaolin, Artskin white, and Ti white artists' oil color.

Objectives Opiod- and/or radiation-induced xerostomia in cancer patients is frequently associated with elevated levels of cariogenic mutans streptococci (MS). Study design In a single-center, single blind 8-week clinical trial at The University of Texas M. D. Anderson Cancer Center, and from an initial sample of 32 patients, we evaluated MS counts in 28 cancer patients receiving chronic analgesic treatment for cancer pain. All patients received escalating doses of pilocarpine (Salagen ® ) tablets, either 2.5 mg to 5 mg or 5 mg to 7.5 mg qid for 6 weeks, followed by placebo qid for a 2-week washout period. Whole resting saliva flow rates (g/5 min) and MS counts were evaluated at pretreatment, 3 weeks, 6 weeks, and 8 weeks. MS samples were obtained by 5-mL saline rinse (15 sec) at each visit prior to sialometry. Results In 19 patients (59%), MS counts exceeded 10 5 CFU/mL. At the end of the 6-week trial, 96% of patients showed a positive response to pilocarpine following a 30-minute postdosing evaluation ( P = .001). MS counts were lower in 17 patients, higher in 6 patients, and nondetectable before and after pilocarpine in 5 patients ( P = .03). Conclusion The reduced MS counts associated with improved saliva flow rates following pilocarpine therapy in this short-term pilot study are encouraging, but further investigation in a larger group of patients over a longer study period is indicated.

Intensity modulated radiation therapy (IMRT) allows for relative parotid salivary gland sparing for patients undergoing treatment for head and neck squamous cell cancer, but is less reliable for sparing the submandibular glands. Cytoprotection with amifostine (Ethyol; Medimmune Inc, Gaithersburg, MD) has been shown to decrease rates of acute and late xerostomia in patients undergoing radiation therapy for head and neck squamous cell cancer. The addition of amifostine to IMRT may augment parotid salivary sparing, and add submandibular/sublingual, and minor salivary gland sparing resulting in greater salivary flow rates and a more physiologic saliva. Eligible patients include those slated to receive definitive IMRT for early oropharynx cancer or postoperative RT, both without chemotherapy, for more advanced cancers. These include T1, T2 and favorable T3 (favorable, exophytic), N0-2b (small volume) M0 oropharynx cancers who are to receive bilateral neck RT. Postoperative patients with nodal metastases, T3 and T4 primaries, perineural invasion, and lymphovascular invasion will be eligible. Patients will receive 30 to 33 fractions. Clinical target volume (CTV) 1 will receive 60 to 66 Gy, CTV2 will receive 60 Gy, and CTV3 will receive 54 to 57 Gy. The mean dose goal for the parotid gland is 25 Gy. Patients will receive fixed-dose amifostine 500 mg subcutaneously 30 to 60 minutes before each radiation fraction. Subjective xerostomia questionnaires will be administered. Whole mouth and individual major salivary gland stimulated and unstimulated saliva will be collected before and after therapy at 6 weeks, 6 and 12 months. Xerostomia outcomes will be correlated with salivary dose volume histogram data. Accrual has not yet begun. The results of this study will give an indication of the objective and subjective benefit of combined IMRT physical parotid salivary sparing and amifostine chemical cytoprotection for combined salivary gland sparing and reduction in the rate of xerostomia in patients undergoing IMRT for head and neck squamous cell cancer.

Few studies have addressed the possible effect(s) of microwave irradiation on the magnetic properties of "permanent" magnets during the fabrication of dental and maxillofacial prostheses.The objective of this study was to investigate the influence of microwave irradiation energy on the retentive force of a magnetic attachment system used in maxillofacial prosthetic rehabilitation.A heat-polymerized PMMA disk (6 cm in diameter) was fabricated. Seven magnets were placed around the wafer in a circumferential fashion: 1 in the center and 6 surrounding it. The 7 magnets were spaced 2 cm from their respective centers. Seven heat-polymerized PMMA cylinders were also used, and a magnet (counter-magnet) was placed in the center of each even with the cylinder's surface. Once the investment had set (45 minutes after mixing), the 7 counter-magnets in the cylinders were placed against the 7 magnets in the acrylic wafer. A second mixture of investment material was added. The flasks were separated, and the acrylic wafer was removed to accommodate the 7 counter-magnets in the base mold in the same geometric configuration and to serve as a "spacer" for the silicone material. A 1:1 mixture of medical grade elastomer (MDX4-4210) and medical adhesive silicone (type A) was packed and compressed, the molds were reclamped, and the excess silicone was removed. The elastomer/silicone wafer was packed and compressed into the test and base molds, the molds were reclamped, and excess silicone was removed. The first group of magnets, designated Group A, received microwave irradiation for 5 minutes at low power (112 W). This procedure was repeated for each group of magnets at the following polymerizing times (n=14): Group B, 10 minutes; Group C, 15 minutes; Group D, 20 minutes; Group E, 25 minutes; Group F, 30 minutes; and Group G, 35 minutes. Measurements of retentive force (N) at 10 mm/min ramp rate of speed of separation was conducted. The specimen rate read 5.0 points/second. Data were analyzed using a 1-way analysis of variance (alpha=.05); individual mean values were compared using the Tukey test (alpha=.05).There were no statistical differences in retentive force between groups D, E, and F (20, 25, and 30 minutes, respectively) or between groups A, B, C, D, F, and G (5, 10, 15, 20, 30, and 35 minutes, respectively). When the microwave-irradiated groups A through G were compared with the control group, there was a significant difference (P.05) in retentive force (N). Group E (25 minutes) showed the largest reduction of retentive force (0.3 N, a reduction of 12%).If a prosthesis is processed using a microwave and contains samarium cobalt magnets, the retentive force may be reduced up to 12% under specific conditions.

Purpose Oral mucositis (OM) causes significant morbidity during the course of radiotherapy (RT) treatment of head-and-neck cancer. It is hypothesized that infection plays a role in the development of OM. We tested the efficacy of iseganan HCl (iseganan), a synthetic peptide with broad-spectrum antimicrobial activity, for preventing RT-associated OM. Methods A multinational, randomized, double-blind, controlled trial was performed on patients receiving primary RT, primary chemoradiotherapy or postoperative RT. Patients were randomized to receive iseganan oral solution plus standard-of-care oral hygiene (SOC), placebo plus SOC, or SOC alone throughout the RT administration period. The severity of OM was assessed by NCI-CTC scoring and clinical symptoms by patient questionnaire. Results A total of 545 patients were randomized to the study. Nine percent of the patients in both the iseganan and placebo groups did not develop ulcerative OM (Grades 2, 3, 4) ( p = 0.998) whereas only 2% of the patients receiving SOC alone remained free of oral ulceration ( p = 0.049). The maximum severity of mouth pain and difficulty swallowing did not differ in patients treated with iseganan or placebo. However, patients in both intervention groups reported less mouth pain and difficulty swallowing than did patients receiving SOC alone. Nausea was the only adverse event that occurred with ≥5% increased frequency in the iseganan group than in either the placebo or SOC groups (51% vs. 42% vs. 46%). Adverse events leading to study drug discontinuation and death did not differ significantly between groups. Conclusion Iseganan oral solution was safe but did not reduce the risk for developing ulcerative OM relative to placebo. Intensified oral hygiene or the administration of the vehicle used to deliver study drug in this trial appears to have reduced the risk and severity of OM. Our results suggest that antimicrobial intervention may not meaningfully affect the pathogenesis of radiation-induced OM.

A partially resected soft palate represents a more significant challenge for effective prosthodontic obturation than for complete soft palate resections. In fact, for some patients it may not be possible to prosthetically rehabilitate with partial soft palate resections, resulting in velopharyngeal dysfunction, which could include hypernasal voice quality and nasal regurgitation of food and liquids. This article presents a technique for recording the contours of a partial soft-palate defect for prosthetic obturation.

Traditional methods of fabricating orbital prostheses rely on the "lost wax" technique to produce a realistic representation of the sculpted pattern produced in the defect. The usual constituents of the mold that reproduces the subtleties of the palpebral fissure are often minute, making them prone to fracture and subsequent dissolution by repeated attempts at pressing each prosthesis. The following method provides a mold resistant to these problems with light-polymerized resin surrounding the palpebral part of the orbital mold.

A technique is presented for modifying the Blom-Singer tracheostoma valve housing to improve peristomal skin adherence for hands-free tracheoesophageal speech production following total laryngectomy. The finished product is thin, flexible, and maintains enhanced tear strength. The edges of a standard housing device for the Blom-Singer valve are trimmed to allow for better accommodation to the tissue surface without distortion. A punch biopsy instrument is used to cut uniform holes around the housing device to allow for permeation of the silicone mixture for better mechanical adherence of the materials.

Laryngectomized, tracheoesophageal speakers who achieve hands-free speech wear a special breathing valve to automatically shunt air into the pharyngoesophagus for speech production. The standard method of attachment is adherence to the peristomal skin with glues and adhesives. The Barton button is a simpler, more efficient alternative that provides intraluminal attachment within the trachea. Although the device is appealing, constraints in standard design and dimensions have limited its success. This article presents a technique for modification of the Barton button to increase its successful use by tracheoesophageal speakers.

This article describes a predictable method for indexing the ocular portion of an orbital prosthesis. Because indexing is performed from the anterior aspect of the cast, damage is minimized, fewer modifications are required, and the mold can be preserved for repeated use.