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Assessment of the quality of life in patients with oral
cavity and jaw cancer in three regions of Bulgaria
Maria Stoikova
Department of Social Medicine and Medical Management, Medical University, Plovdiv,
Bulgaria
Author and address for correspondence:
Maria Stoikova, MD
Department of Social Medicine and Medical Management, Faculty of Medicine
Medical University – Plovdiv
15A Vasil Aprilov Blvd
Plovdiv 4000
Bulgaria
Fax: +359 32 602 534
E-mail: brami@abv.bg
Summary
Purpose: The aim of the present study was to assess the quality of life in patients with
oral cavity and jaw cancer, using an original rating scale.

Materials and methods: In order to assess the quality of life in such patients an
original rating scale was developed. It was validated. Non-parametrical analysis, Van der
Waerden analysis for small samples and graphic analysis were used for statistics.
Results: Results showed that most patients were rated as grade III or IV according to
the five grade scale. Their life quality was significantly reduced, resulting in depression and
despair. Reconstruction and prosthesis implantation and social rehabilitation were needed in
these patients. Quality of life was assessed in 19 patients prior to and following prosthesis
implantation. Prior to implantation most patients were rated as grade III or IV, whereas the
majority of them were rated as grade 0 or 1 following prosthesis implantation.
Conclusion: After assessment of life quality, patients rated as grade III or IV should
be allowed access to complex medical management, including prosthesis implantation and
social rehabilitation.
Key words: rating scale, quality of life, prosthesis
Introduction
A number of module questionnaires and rating scales have been used in an attempt to
assess the quality of life in patients with oral cavity and jaw cancer. Specific for defect
location as well as unspecific rating instruments have been applied – Head & Neck Cancer
Modul, VFQ [5,13,17]. Most of them focus on health problems, functional impairment and
depression as a result of disfigurement [1,2,5,6,7,8,9,12,14,15,16,17,18]. Some authors
consider them detailed and labor consuming – in J. Kollbruner’s et al. opinion, the scales they
used, consisted of 241 test items and 19 life quality aspects and thus was difficult to apply
[11]. A number of authors developed their own rating scales – Schleiphake et al. used a
standardized scale, consisting of 22 test items [15]. A new, easy to use rating scale to assess
the quality of life in patients with oral cavity and jaw cancer is presented in this study.

Material and methods
The aim of the present study was to assess the quality of life in patients with oral
cavity and jaw cancer. An interview was administered to 103 patients from Plovdiv, Smolyan
and Pazarjik region (Bulgaria). All of them presented with oral cavity and jaw cancer (141-
145;170.0;170.1, according to the International Classification of Diseases ICD - 9). Lip
cancer was excluded.
In this study an originally developed, (not a standard) rating scale of quality of life
was used. It was developed, based on evaluation and analysis of functional impairment in
such patients. The scale was validated in a pilot study of 30 patients, yielding a very good
value of Cronbach’s alpha coefficient – α = 0.91. External validity was assessed, comparing
ratings by two independent scorers – the researcher and a dentist, performing prosthesis
implantation in the oro-facial region. Nineteen patients were evaluated. Results showed a high
correlation – p

Figure 1. Assessment of quality of life in the patients, studied.
Results showed that most patients were rated as grade 3(65.05±4.69) or
4(22.33±4.10). They had impaired speaking and feeding, combined with disfigurement and
pain or both. Functional impairment in such patients is severe, leading to despair and
depression and no faith in favorable outcome. Other authors’ studies present similar results
[3,10]. Multiple surgical interventions - re-operations and prosthesis implantation are the only
option in such patients, as an element of social rehabilitation [4].
Prior to analyzing the role of prosthesis implantation, the quality of life of these
patients was rated according to the disease stage (Figure 2).
70
60
50
40
30
20
10
0
%
0 grade 1st grade 2nd grade 3rd grade 4th grade
I and II dis.stage
III and IV dis.stage
Figure 2. Assessment of quality of life according to disease stage.
Results show that most patients were rated as grade 3 or 4. Significantly reduced
quality of life (grade 3) was reported by most patients in stage I or II of the disease. Severely
reduced life quality (grade 4) was reported by a nearly equal number of patients from both
groups – about 20 % in stage I and II of the disease and in stage III or IV of the disease. This
is due to the fact that patients with stage I or II receive surgical treatment, which in stage II is

followed by radiotherapy. Stage III patients receive only radiotherapy, stage IV- radiotherapy
and chemotherapy. This treatment strategy significantly impairs normal functioning even in
stage I and causes severe patient’s discomfort. Thus, all patients with oral cavity cancer have
a reduced quality of life regardless of the disease stage and need complex treatment by a team
of specialists – the so called social rehabilitation.
In order to prove that prosthesis implantation improves the
quality of life such
patients, they were rated using the scale prior to and following reconstruction (Figure 3).
%
80
70
60
50
40
30
20
10
0
0 grade 1st grade 2nd grade 3rd grade 4th grade
prior to proth. Inplant.
following proth. Inplant.
Figure 3. The quality of life of patients before to prosthesis implantation and after
prosthesis
implantation.
The date show that there is a significant difference, regarding quality of life prior to
and following prosthesis implantation. Before prosthesis implantation most patients were
rated as having reduced quality of life (grade 3 or 4). After implantation most of them were
rated as grade 0 or 1, indicating that problems with speaking, feeding, disfigurement and pain
have been eliminated. The difference between the two groups is statistically significant
p

small samples was used ( Table 1). Table 1 shows the proportion of patients rated as grade 0
and 1 prior to prosthesis implantation and rated as grade 3 or 4 following implantation. The
difference is statistically significant.
The results of the study illustrate the need of prosthesis implantation in patients with
large maxillo-facial defects. Apart from the improved sense of well –being and recovery of
vital functions, it is also a contributing factor to patients’ coping with the illness. Most
authors consider coping structure crucial to patients’ illness management [4]. It is necessary
in such patients after assessment of quality of life, those rated as grade 3 rd or 4 th grade to
receive adequate medical care and social rehabilitation.
Conclusions
1. Patients with oral cavity and jaw cancer have a reduced quality of life regardless of
disease stage and require complex management by a team of specialists.
2. Prosthesis implantation improves quality of life in patients with oral cavity and jaw
cancer.
3. This scale is easy to use and could be applied as a quality of life assessment
instrument in Clinics of Oro-facial Surgery. This would facilitate postoperative care
and social rehabilitation of such patients.

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Table 1. Assessment of quality of life prior to and following prosthesis implantation in 19
patients
Grade Prior to prosthesis implantation Following prosthesis
implantation
number % Sp number % Sp
0 0 4,76 4,54 15 76,19 9,08
1 st 0 4,76 4,54 3 19,04 8,37
2 nd 1 9,52 6,25 1 9,52 6,25
3 rd 9 47,61 10,64 0 4,76 4,54
4 th 9 47,61 10,64 0 4,76 4,54