|Year : 2015 | Volume
| Issue : 1 | Page : 8-13
Oral health-related quality of life in non-surgical treatment of mandibular fractures: A pilot study
Kevin U Omeje1, Akinwanle A Efunkoya1, Adetokunbo R Adebola2, Otasowie D Osunde3
1 Lecturer, Faculty of Dentistry, Bayero University, Kano and Consultant, Oral and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Preventive Dentistry, Faculty of Dentistry, Bayero University, Kano and Consultant, Oral and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Dental Surgery, Maxillofacial Unit, University of Calabar/University of Calabar Teaching Hospital, Calabar, Nigeria
|Date of Web Publication||4-Jun-2015|
Otasowie D Osunde
Department of Dental Surgery, Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar
Source of Support: None, Conflict of Interest: None
Background: Absence of surgical stress and the limitations associated with maxillo-mandibular fixation have been identified as advantages with non-surgical management of mandibular fractures where indicated. This treatment modality entails close observation, feeding on soft diet, use of analgesics and antibiotics alongside warm saline mouth rinses. This study serves as a pilot to evaluate oral health-related quality of life (QoL) for patients with mandibular fractures who were managed non-surgically in a Nigerian teaching hospital. Patients and Methods: A total of 153 patients were evaluated prospectively over the space of 1 year from which 10 patients met the selection criteria for non-surgical treatment of mandibular fractures. Evaluation at presentation was done using General Oral Health Assessment Index questionnaire. The questionnaire was subsequently completed during reviews at day 1, 6 weeks, and 8 weeks, respectively. Results: There was acceptable healing of all the fractures with a significantly improved mean QoL outcome from 41.42 ± 1.14 at presentation to 59.90 ± 2.00 at 8 weeks review. Conclusion: Although very few patients meet the criteria for non-surgical treatment of mandibular fractures, it is an acceptable treatment option in patients with fractures of the mandible. This form of treatment in such selected cases results in satisfactory fracture healing and acceptable QoL to the patient.
Keywords: Mandibular fractures, non-surgical treatment, quality of life
|How to cite this article:|
Omeje KU, Efunkoya AA, Adebola AR, Osunde OD. Oral health-related quality of life in non-surgical treatment of mandibular fractures: A pilot study. Niger J Exp Clin Biosci 2015;3:8-13
|How to cite this URL:|
Omeje KU, Efunkoya AA, Adebola AR, Osunde OD. Oral health-related quality of life in non-surgical treatment of mandibular fractures: A pilot study. Niger J Exp Clin Biosci [serial online] 2015 [cited 2017 May 24];3:8-13. Available from: http://www.njecbonline.org/text.asp?2015/3/1/8/158144
| Introduction|| |
The standard of care for mandibular fractures is reduction and immobilization of the fractured segments, using either internal fixation with bone plates or intermaxillary fixation (IMF) with arch bars and interdental wires.  These two approaches constitute the open and closed reduction of mandibular fractures and various techniques have been well-documented in the literature. ,, Open reduction has the advantage of early post-operative mobilization and prompt return to work. However, disadvantages of open reduction (such as the need for general anesthesia, extra-oral incisions in some cases, second operation to remove implants, and possibility of neurovascular damage) have made closed reduction to remain an option to consider in the treatment of mandibular fractures. The need for IMF for 2-6 wks however makes closed reduction an unpopular treatment modality, despite the lower cost and lower sensitivity to professional experience. ,
While the superiority of one technique over the other is still a matter of an on-going debate, selected cases of mandibular fractures can be managed by a conservative or non-surgical approach. The selection criteria for non-surgical treatment include patients with undisplaced fracture segments and satisfactory occlusion on clinical and radiological assessment, normal mandibular range of motion as well as healthy compliant patients with good oral hygiene.  Such cases are managed by close observation of the fractures, feeding on soft diet, use of analgesics and antibiotics alongside warm saline mouth rinses. The advantages of non-surgical method include cost-effectiveness, absence of surgical stress and limitations associated with maxillo-mandibular fixation (MMF).  Patients selected for this form of treatment however have to be compliant with regular follow-up appointments to ensure satisfactory fracture healing with no untoward developments such as fracture displacement which, if present, may necessitate surgical treatment. Thus, normal daily life activities of affected patients may be disrupted because of the several follow-up visits required.
Quality of life (QoL) studies are accepted method of evaluating effects of treatment techniques from patients' perception rather than the clinician's point of view.  These studies are of value in determining the acceptability of treatment to patients and the effects of such treatments on patients' health, lifestyle, and disposition. Despite the obvious advantages of conservative/non-surgical approach to the treatment of mandibular fractures, there is paucity of information on measurement of QoL of patients who had undergone this form of treatment.  This paper is a pilot study evaluating the QoL of patients undergoing non-surgical management of mandibular fractures in a Nigerian teaching hospital.
| Patients and Methods|| |
A prospective pilot study on non-surgical management of mandibular fractures was conducted at the Maxillofacial Surgery Unit of Aminu Kano Teaching Hospital (AKTH) Kano from January to December 2012. Patients with mandibular fractures were recruited into the study. The study protocol was approved by the Research and Ethics Committee of our institution and all selected patients gave written informed consent. The inclusion criteria for the study were subjects who sustained only mandibular fractures, those with undisplaced mandibular fractures on clinical and radiographic examination, subjects with satisfactory occlusion and those with good oral hygiene or who can be motivated to maintain good oral hygiene as well as subjects with normal range of mandibular motion. The exclusion criteria were subjects with other facial fractures in addition to mandibular fractures, displaced mandibular fractures, high condylar fractures (that may require mobilization of the joint to prevent temporomandibular joint ankylosis), subjects who declined to participate in the study as well as those below 14 years of age.
Conservative/non-surgical management entailed use of antibiotics (cefuroxime/Zinnat tablets 500 mg 12 hourly for 5 days and metronidazole/Flagyl tablets 400 mg 8 hourly for 5 days), analgesics diclofenac potassium/Cataflam tablets 50 mg 12 hourly for 3 days, warm saline mouth rinses before and after meals, feeding on soft diet, and regular weekly follow-up except for the first 2 weeks when they were reviewed twice/weekly. This review was to ensure that subjects maintained good oral hygiene and adhered to the instructions on feeding, medication, and warm saline rinses.
All the subjects had prophylactic scaling and polishing by dental therapist retrained for the purpose of the study to ensure standardization prior to treatment. Radiographs (postero-anterior view, right and left lateral oblique views of the jaws) were taken at presentation and subsequently at 2 weeks, 4 week, and 8 weeks. The researcher examined the patients and documented the findings. The data were recorded on a proforma and a standard General Oral Health Assessment Index (GOHAI)  questionnaires were administered by interview method and completed to obtain the initial score and the scores during reviews on day 1, 6, weeks and 8 weeks, respectively. The interviewer translated the questions and responses into the local dialect (Hausa) for subjects who were not literate.
GOHAI questionnaire assesses the oral health function of the patient in three domains namely physical, psychosocial, and pain domains. Physical domain assesses functions related to eating, speech and swallowing; psychosocial domain assesses functions related to worry and concern about oral health, dissatisfaction with appearance, self-consciousness about oral health, and avoidance of social contacts because of oral problems while pain domain evaluates discomfort and the use of medications to relive pain from the mouth.
The 12-item/question GOHAI index score ranges from 12 to 60, reflecting 1 for the least score (never) and 5 for the maximum score (always) for each individual item. The scores for each item are reversed (1 = 5, 2 = 4, 3 = 3) except for items 3 and 5 (which were asked in a "positive" sense and therefore did not need to be reversed). GOHAI is analyzed by summing up all the individual scores of the 12-items/questions. A higher GOHAI score represents a more positive oral health status.
The collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc, Chicago, IL). Absolute numbers and simple percentages were used to describe categorical variables. Quantitative variables were described using measures of central tendency (mean, median) and measures of dispersion (range, standard deviation) as appropriate. The chi-square test was used to assess the significance of associations between categorical groups, and inferential statistics was done using student's t-test and analysis of variance (ANOVA) as appropriate. A P - value of 0.05 or less was considered statistically significant.
| Results|| |
A total of 153 patients with mandibular fractures were seen during the study period, of which 10 patients met inclusion criteria for the study. Of the remaining 143 patients, 100 were treated by closed reduction/MMF while 43 by open reduction, immobilization and fixation (ORIF) based on standard indications for such treatments. The 10 patients managed conservatively had their ages ranging from 19-35 years with a mean age of 25.5 ± 5.87 years, and gender ratio of 9:1 (M:F). They were all Nigerians and of Hausa descent.
Healing of the fracture sites started and progressed within the review periods. Complaints on intensity of pain were noticed to reduce at each review appointments. Radiographically, minimal displacement of the fractures was noticed in 4 patients within the first 2 weeks. However, there was no associated functional impairment. One of the patients had occlusal disparity which was eventually managed by selective occlusal grinding [Table 1]. None of the patients presented with post-operative malocclusion which necessitated re-treatment. Demographics of the subjects, fracture displacement and need for additional treatment are presented in [Table 1].
|Table 1: Demographics of patients treated for mandibular fractures by non-surgical method|
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The GOHAI score for the patients that had non-surgical treatment are presented in [Table 2]. The mean GOHAI score for patients managed by non-surgical/conservative technique was significantly high throughout the periods of review (P = 0.00) [Table 2]. The study showed that by final review (8 weeks), percentage response to the entire questions in GOHAI approached 0 except for questions 3 and 5 which equally recorded 100% [Table 3]. Domain scores for non-surgical management using GOHAI are presented in [Table 4].
|Table 2: Mean quality of life scores for patients managed by non-surgical means at the various review periods (n = 10)|
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|Table 3: The percentage often/always response frequencies and mean values for the outcome measures at various review periods (n = 10)|
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|Table 4: Mean quality of life scores for the domains in patients managed by non-surgical means (n = 10)|
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| Discussion|| |
The present study evaluated QoL in patients treated for mandibular fractures using non-surgical/conservative approach. Age and gender distribution of these patients are consistent with the findings in subjects with mandibular fractures as reported across the world. ,, Male preponderance is a common finding in trauma; this has been related to the more active and outdoor lifestyle of males.  Age findings in our study are also consistent with reported findings from other publications for similar reasons. , Although the small number of patients that met our criteria for recruitment amidst the numerous patients evaluated may limit significant deductions, our results showed that patients treated by non-surgical or conservative methods had significantly high QoL scores.
The QoL scores from non-surgical management of mandibular fractures in this study measured at the final review period were higher than those reported by Omeje et al.,  at similar review periods for patients treated by closed reduction with MMF (56.97 ± 1.65) and open reduction/internal fixation (56.67 ± 2.56) from the same center. This may suggest that non-surgical management may be considered alongside closed reduction and open reduction as an option for mandibular fracture treatment where indicated. It is important to note that such cases should have undisplaced fractures with acceptable occlusion. The presence of other facial fractures may be a modifying factor that may require further study since this was not reflected in this study.
The pain domain of GOHAI was noted to be most affected at the early periods of the review. This is understandable as pain is often the reason for seeking treatment. The reduction of pain over time may reflect the effect of time and healing of the fracture. Absence of significant reduction in the physical and psychosocial domains is more difficult to explain. This may reflect our study population's perception of trauma and high morale resulting from absence of surgical treatment.
The basis for conservative management of mandibular fractures stems from a theory by Gezhal et al.,  that intact periosteum maintains sufficient stability which may be enough to permit ossification. Osteogenic cells derived from periosteum and bone marrow produce growth factors important for bone regeneration. The acceptable result obtained in our study may be attributable to the young age of our study population with blood supply to the mandible from both endosteal and periosteal supply. Endosseous blood supply is known to be relatively absent in the elderly population and may account for poorer bone healing in this age-group. Guerrisi  argued that incomplete fractures or non-displacement of fractures are associated with first intension osseous reparation.
Mechanical factors related to active mobilization of the jaws in an unfixed fracture in this modality of treatment have been documented to not only result in bone fragment displacement but reduction in quality or quantity of callous produced which ultimately will affect bone healing process.  Prescription of soft diet for patients managed non-surgically may also limit mechanical forces from active mastication which may lead to increased inter-fragmentary mobility and poor fracture healing.
The role of gender in QoL assessment is a subject that may require further evaluation. The only female subject in our study required occlusal grinding before satisfaction was achieved. This observation may be related to higher aesthetic and functional demands by women. Occlusal grinding is indicated as treatment for patients with minor cuspal inteferences who have no other significant occlusal mal-alignment. In these group of patients, selective grinding of "high spots" is often sufficient to restore occlusal harmony without the need for further surgical treatment.
The disposition of the Hausa ethnic group which constituted our study population may have played an important role in observed QoL outcome. This ethnic group in Nigeria has a strong positive disposition about life. Cultural and religious factors have been adduced to explain this. The subjects managed in our study all received non-steriodal anti-inflammatory analgesic agent without the need for modification to prevent gastric mucosal erosion. This was because none of the subjects in our study had history that contraindicated such treatment.
Non-surgical treatment has been documented in the literature for the treatment of comminuted mandibular fractures. , Advocates of non-surgical technique in this situation argue that manipulation of fracture segments and stripping of periosteum during open reduction may lead to devitalization of tissues. ,, In contrast, proponents of open reduction argue that devitalization and necrosis does not result from tissue manipulation and stripping of periosteum but rather from lack of stabilization of bone fragments. They further suggest that closed reduction would result in inter-fragmentary mobility providing an inadequate environment for healing. 
Ghazal et al., observed from treatment of 28 patients by non-surgical method that the periosteum provides adequate stability needed for bone repair. They also argued that certain amount of movement is required for bone repair especially in the elderly. They noted that repair does not depend on only mechanical factors but also on an intact periosteum and bone marrow which provide osteogenic cells. They recorded spontaneous healing of fractures in the 28 patients; however, two patients that had tooth in their fracture line had extraction of such teeth.
In a resource-poor environment like ours where cost of surgical treatment is borne by patient, coupled with the limited theatre space and available manpower for surgical treatment, non-surgical management may be encouraged for selected mandibular fractures. This treatment modality will reduce the cost and burden of surgery on patients. In addition, the much valued operating time can be saved and may be utilized for other more emergent conditions. Non-surgical treatment of mandibular fracture however requires stringent selection criteria, frequent patient reviews, and radiographic exposure which may reduce the acceptability of this form of treatment.
[Additional file 1]
| Conclusion|| |
Although very few patients meet the criteria for non-surgical treatment of mandibular fractures, it is an acceptable treatment option in patients with fractures of the mandible. This form of treatment in such selected cases results in satisfactory fracture healing and acceptable QoL to the patient. Our study showed satisfactory QoL in subjects who had non-surgical management of mandibular fractures.
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[Table 1], [Table 2], [Table 3], [Table 4]