Prole of Oncological Patients Needing Rehabilitation by Dental and Bucomaxillofacial Prostheses in a Brazilian Subpopulation

Purpose: This study aimed to identify the prole of cancer patients in need of rehabilitation with oral and/or buccomaxillofacial prostheses, as well as to evaluate the possible reasons for not concluding the rehabilitation. Materials & Methods: This is a retrospective observational study carried out at the Dentistry Department of the Mato Grosso Cancer Hospital, Cuiabá, MT, Brazil, through the evaluation of the medical records of patients attended from April 2017 to November 2019. Results: The study population comprised 256 patients who met the research inclusion criteria. It was found that 30.90% of the patients were elderly, 65.6% were men, 70.3% brown, 27.3% retired, 49.2% married and 52% coming from municipalities of the interior of the state of Mato Grosso. From the total of patients, 67.23% reported smoking and 53.9% alcohol consumption. As for the location of the tumor, 57.4% had it in the head and neck region, 55.1% of which were epidermoid carcinoma and in 28.9% of cases the disease stage was IV. Most of the patients (60.2%) completed prosthetic rehabilitation, with total prostheses predominating. The main reasons for not completing the rehabilitation were the patient's death and weakness. Conclusions: Patients who started treatment in more advanced stages of cancer had a greater chance of not completing the prosthetic rehabilitation, and the incompletion of rehabilitation treatment was directly related to the patients’ death and the state of weakness. were collected. Regarding the characteristics of prosthetic rehabilitation, data were collected regarding the types of maxillary prostheses (total, partial, total obturator, and partial obturator), mandibular (total or partial), and facial; and the reasons for not completing rehabilitation.


Introduction
Cancers in the head and neck region profoundly affect the quality of life of patients, as they can affect the patient's aesthetics and are a constant reminder of the disease. These cancers are emotionally debilitating for patients and their families 1 .
The diagnosis of cancer negatively impacts the patient's life and feelings of fear and suffering are common throughout the process, which begins with the diagnostic phase, followed by therapy and survival 2,3 . Most post-treatment patients, whether surgical or not, remain in subsequent follow-up visits for an average period of 10 years 4 .
Cancer treatment causes from mild to more severe adverse effects 5 . Large facial defects compromise vital functions such as breathing, chewing, speaking, swallowing and aesthetics. A prosthetic reconstruction of facial defects helps to restore functional disabilities and assists in the recovery of the patient and his family 6 .
In the treatment of tumors in the head and neck region, patients are also often submitted to surgeries that have a serious impact on quality of life and can impair appearance and functional characteristics 7 .
Mutilations on the face can bring very important aesthetic and functional damage to patients, causing morphofunctional and psychosocial changes leading the individual to social and family isolation. Thus, it is imperative that health professionalscommit to their rehabilitation 8 .
Prosthetic treatment is indicated to regain lost oral functions, improve physical appearance and enable patients to participate in daily activities with greater con dence 9 . The absence of teeth, not replaced by prosthesis also negatively affects the quality of life of cancer patients 10 .
Given the important demand for dental care of patients with malignant neoplasms and the positive impact of rehabilitation on their quality of life, this study aims to outline the pro le of cancer patients rehabilitated with dental and/or maxillofacial prostheses, and also the reasons for inconclusion of rehabilitation treatments.

Materials & Methods
Population selection Data collection was performed by surveying the medical records of patients treated at the Dentistry Department of the Cancer Hospital of Mato Grosso, Cuiabá, MT, Brazil, from April 2017 to November 2019. This period was selected because the hospital uses a single medical record for each patient and the medical records are managed by an information system that was replaced in April 2017.
All prosthetic care performed in the period were surveyed in the Care Management System, reaching the total of patients who had an indication for prosthetic rehabilitation treatment in the period. Patients of both sexes and of any age were included. Patients who were rehabilitated but had no con rmed diagnosis of cancer and patients whose information was not possible to be collected in the respective medical records were excluded.
Collected data Information about age; sex; race/color of skin (de ned through the recommendation by the Brazilian Institute of Geography and Statistics -IBGE) 11 ; origin (separated into two distinct groups: state capital and cities from the interior of the state); profession; marital status; smoking and drinking habits; and family history of cancer were collected.
As for the characteristics of the disease, the tumor location, histological type, stage of the disease, and the cancer treatments performed (surgery, radiotherapy and chemotherapy) were collected. Regarding the characteristics of prosthetic rehabilitation, data were collected regarding the types of maxillary prostheses (total, partial, total obturator, and partial obturator), mandibular (total or partial), and facial; and the reasons for not completing rehabilitation.
Patients who met the inclusion criteria, but whose medical records did not present the information on completing the rehabilitation or installation of the prosthesis, were actively sought by telephone and questioned as to the reason for the fail in the conclusion of the rehabilitation treatment. Those patients or their relatives contacted, gave different answers to the fail in the conclusion of the treatment. These responses were grouped into ve distinct groups, as follows: patient died before completing the rehabilitation treatment; patient interrupted the treatment because of weakness; patient is still in rehabilitation treatment; patient completed the rehabilitation in somewhere else and patients with no de ned response (corresponding to the cases in which telephone contact was unsuccessful).

Data analysis
A single researcher collected the data and organized in an Excel spreadsheet. Descriptive statistical analysis was performed for the studied variables. The result was presented as absolute and relative frequencies. To analyze possible associations between independent variables and the dependent variable not completing the prosthesis and between the independent variables and the dependent variables reason for not completing the prosthesis, multinominal logistic regression was applied, following previously used methodology 12

Results
In the present study, 470 hospital records were analyzed, among which 256 records t the research inclusion criteria. The other patients were rehabilitated, but were excluded because they had no con rmed diagnosis of cancer or the information was not possible to be collected in the respective medical records.
The distribution of patients according to demographic characteristics, smoking and drinking habits and family history of cancer are shown in Table 1. The distribution of patients according to the treatment and characteristics of the tumor is shown in Table 2. Figure 1 shows the owchart of the characteristics of prosthetic rehabilitation and reasons for not completing the prosthetic treatment.
The analysis of the association between age, marital status, city of origin and cancer staging with the completion of the prosthesis using multivariate logistic regression is shown in Table 3. The association between the stage of cancer and the reason for not performing the prosthesis using multivariate logistic regression is shown in Table 4.

Discussion
Cancer patients rehabilitated with dental and/or maxillofacial prostheses are elderly and the main reason for not concluding the treatment was the patient's death. The population studied was predominantly of married and retired men. As for the origin 52% of the patients are from cities in the interior of the state and 70.3% of the patients are brown. Caetano et al. 13 ,evaluated the quality of life, body image and selfesteem in patients with sequelae after treatment of head and neck cancer, candidates for prosthetic rehabilitation. They had a sample of 10 patients, and also found a predominance of male patients (60%); 50% married; 30% aged 51 to 60 years, 40% farmer, 30% retired; 60% were from the interior of the state.
In a study by Rettig and D'Souza 14 , they mention that two of the main causes of head and neck cancer are the use of tobacco and alcohol. Gomes et al. 15 , analyzed 33 patients, where 84.38% and 87.50% of the individuals used or were still in use of tobacco and alcohol respectively.
The most affected anatomical sites by the tumors in this population were head/neck (57.4%), breast (12.1%) and prostate (10.3%). Breast and prostate cancer are among the most prevalent in Brazil 16 ,the greater number of patients with tumors in the head and neck in this study can be explained because these patients always have their oral health analyzed in the Dentistry Department before starting the anitineoplastic treatment and, with that, they already establish a connection, returning later for oral rehabilitation.
The most frequent histopathological diagnosis was epidermoid carcinoma with 141 cases (55.1%) and the most frequent disease staging was IV with 74 cases (28.9%). Epidermoid carcinoma is the most frequent malignancy among tumors in the head and neck region and the sixth most common cancer worldwide 17 .
Of the population studied, 154 patients (60.2%) completed their rehabilitation with dental prostheses, including 3 facial prostheses, 148 maxillary prostheses, including 11 obturators, and 126 mandibular prostheses. Quispe et al. 18 , evaluated 75 individuals, but of this group only 30 were cancer patients. The research assessed the need for maxillary and mandibular prostheses, the data collected were: 21 patients needed a maxillary prosthesis: to replace one element (10%), to replace more than one element (33.3%), needs prosthesis combination (13.3%) total prosthesis (13.7%); 29 patients used mandibular prosthesis: to replace more than one element (70%), required the combination of prostheses (3.3%), total prosthesis (23.7%). Joo et al. 7 , cites in his research that patients undergoing oncological treatments may have several sequelae, impairing masticatory function, swallowing, aesthetics, so the use of total or partial obturator prosthesisis an alternative to remedy such sequelae and enable a better quality of life for the patient Parameswari et al. 19 also concluded in their research that prosthetic rehabilitation with obturator prosthesis restores the missing intraoral structures and acts as an anatomical barrier between the oral and nasal cavities, restoring function and aesthetics.
The study was carried out at the Cancer Hospital of Mato Grosso, located in the city of Cuiabá, MT. The Cancer Hospital of Mato Grosso uses a unique medical record for each patient, regardless of the treatments that are performed in different departments of the institution. When working with the medical records, there was a lack of relevant information. The absence of this information impaired the analysis and represents a limitation of this study. This limitation is often found in studies that work with secondary databases, which were not collected speci cally for research. However, it is compensated by the possibility of providing information on a large number of patients quickly and agile over an extended period of time 20 .

Conclusion
The patient rehabilitated with dental and maxillofacial prostheses is mainly male, elderly, brown, married, from cities in the interior of the state, smoker and alcoholic with a history of cancer in the family. They had cancer in the head and neck, the epidermoid carcinoma type, in stage IV and underwent surgery, radiotherapy and chemotherapy. The most performed prostheses were total. The main reasons for not completing the rehabilitation were the patient's death and weakness. Patients who started treatment in more advanced stages of cancer had a greater chance of not completing prosthetic rehabilitation, and had the inconclusion of rehabilitation treatment related to death and weakness.

Declarations
Funding: None to declare. Availability of data and material: Not applicable.
Code availability: Not applicable.
Authors' contributions: All authors have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data. All authors participated on drafting the article or revising it critically for important intellectual content. All authors approved of the version to be published and all subsequent versions.  Figure 1 Flowchart of prosthetic rehabilitation characteristics and reasons for not completing the prosthetic treatment.