Abstract
To evaluate the quality of life in the post maxillectomy patients due to Coronavirus disease 2019 (COVID-19) associated Mucormycosis (CAM) following rehabilitation with obturators. The study also described the management and treatment outcomes of CAM patients. The study included 80 confirmed patients of CAM. The demographic profile, clinical presentations, predisposing and risk factors, and treatment outcomes were studied. Surgical and medical outcomes were expressed as percentages. After surgical debridement, 27 out of 80 patients were rehabilitated with obturators. The quality of life (QOL) of post debridement at 1 month (T1) vs. post 3 months (T2) of obturator use was measured using the oral health impact profile 14 (OHIP-14) scale. Maxillary sinus was involved in 98.75%, Ethmoid sinus in 51.25% and Sphenoid sinus in 26.25%. Surgical management involved Infrastructure maxillectomy in 56.25%, subtotal maxillectomy in 23.75%, and total maxillectomy with zygoma debridement in 20% of cases. Maxillary sinus debridement was done in 100%, Ethmoid sinus in 51.25%, and Sphenoid sinus in 26.25%. Medical management involved administration of intravenous Amphotericin B (total 3–5 g), and Posaconazole 300 mg OD for 3 months. The measured QOL using mean scores of each domain and the total score of OHIP-14 were lower at T2 (25.5 ± 6.809) compared to T1 (49.55 ± 9.822), (indicating better treatment outcomes) and were found to be statistically significant (P < 0.001). Early diagnosis, controlling risk factors, combined aggressive surgical and medical management reduces the morbidity and mortality of the patients. Early rehabilitation of the maxillectomy defects in CAM patients with temporary obturators mitigates deficient mastication and speech, thereby leading to improved function, aesthetics, and social well-being, and improving the overall QOL of these patients.
Keywords: COVID-19, Mucormycosis, Obturators, Quality of life
Introduction
The catastrophic effect of Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in close to 7 million deaths worldwide as per WHO. The advent of COVID-19 has amplified the immunosuppression in patients with existing comorbidities, predisposing them to many opportunistic invasive bacterial and fungal infections [1]. Mucormycosis, a rare aggressive saprophytic fungal infection caused by species of the genus Mucor of the order Mucorales [2] has led to significant morbidity and mortality since the outbreak of COVID-19. The past 3 years has seen rapid surge in the incidence of COVID-19 associated mucormycosis (CAM), with the global incidence of 0.005 to 1.7 per million population; the prevalence is 80 times higher in India compared to the developed countries [3]. With a male predisposition of 70.4% [4], the most common form of presentation is rhino-orbital-cerebral mucormycosis, followed by pulmonary, cutaneous, gastrointestinal, disseminated, and renal mucormycosis. The Mucorales gain access to the nose and nasopharynx by inhalation of the spores, thereby spreading to the paranasal sinus (maxillary, ethmoid), orbit and the intracranial fossa in patients with reduced cellular and humoral defenses [5, 6].
The indiscriminate use of prolonged and high dose corticosteroids [4], Tocilizumab [7], long term hospitalization, prolonged invasive or non-invasive ventilation due to hypoxia, poor hygiene status predisposes for the fungal osteomyelitis. The other risk factors include diabetes mellitus, diabetic ketoacidosis, neutropenia, chronic renal failure, acquired immunodeficiency syndrome, malignancy, solid organ or hematopoietic cell transplantation, iron chelating agents such as deferoxamine [8]. Another debated pathophysiology is that the severe COVID-19 infection leads to rampant endothelial damage, which upregulates the endothelial receptor glucose regulated protein (GRP 78) thereby promoting increased adhesion and penetration of the Mucorales to the endothelium. The persistent hypoxia, acidic environment, high ferritin level, hyperglycemia, decreased phagocytic activity of the white blood cells, angioinvasion, and hematogenous dissemination of these Mucorales cause thrombosis and necrosis of involved tissues, further leading to progression of CAM [9].
The surgical management involves aggressive surgical debridement, which often leads to surgical defect. These maxillectomy defect impede the form, function, and the overall quality of life (QOL) of the patients. The rehabilitation of these maxillectomy defects using immediate obturators help in deglutition, reduces the nasal regurgitation, facilitates the speech, and restores the esthetics of the patients.
No doubt, the oral rehabilitation with the dental implants is the final restoration for these patients, but the requirement of disease-free period prior implant supported prosthesis is the mainstay for the success in these patients. The gross maxillary defects and lost dentition during the waiting period for the disease control can be well managed with temporary obturators as they restore function, hygiene as well as improve psychological and social state of patient.
There exist lacunae in the literature regarding the psychological state of the patients after debridement/maxillectomy in Mucormycosis patients, the authors have described the management of CAM and evaluated the impact on quality of life after rehabilitation with an obturator.
Materials and Methods
Trial Design and Ethical Approval
A single center, prospective cohort study was conducted at a tertiary care institute after getting approval from the Institutional Ethics Committee.
Settings and Consent
All patients presenting with Rhino-orbital- cerebral mucormycosis (ROCM) were screened from May 2021 to January 2022. The eligibility criteria were followed for recruitment into the study for evaluation. All the procedures done for this study complied with the Helsinki Declaration of 1975 and written informed consent was taken from all the patients.
Eligibility Criteria
Inclusion criteria: All patients of any age presenting with ROCM (Microbiological proven on Potassium hydroxide mount or KOH mount). The study also included patients with comorbidities and risk factors associated with CAM.
Exclusion criteria: Patients with systemic mucormycosis- pulmonary or disseminated were excluded from the study. Also, the patients who did not give consent for participation in the study were excluded.
Sample Size Calculation
A convenient sample was taken including maximum number of patients in a stipulated time frame from May 2021 to till January 2022.
Diagnosis and Management
Standard imaging protocol of Orthopantomogram (OPG) and/or Paranasal Sinus view (PNS), Contrast enhanced Computed Tomography (CECT) and/or Magnetic Resonance Imaging (MRI) was followed for all the patients. Hematological investigations such as Complete Hemogram (CBC), Erythrocyte Sedimentation Rate (ESR), Blood Sugar profile, Liver Function Test (LFT), Serum Electrolytes and Viral markers (HIV/HBV/HCV) were done for all the patients. Potassium hydroxide (KOH) mount staining, fungal culture and histopathological assessment were done for all the patients.
All COVID-19 associated Mucormycosis patients were admitted in specifically designated wards having Critical Care Unit (CCU) beds, High Dependency Unit (HDU) beds and general beds. A multidisciplinary team comprising of ENT surgeons, Oral & Maxillofacial Surgeons, Infectious Medicine specialists, Endocrinologists, Ophthalmologists, Neurosurgeons, Pediatric Medicine & Surgery specialists, as per organ involvement, managed these wards, while Microbiologists, Pathologists, Biochemists and Radiologists provided high quality diagnostics support. These patients were operated in specifically designated operating rooms.
Multidisciplinary team was involved to facilitate early diagnosis with prompt initiation of antifungal therapy and aggressive early surgical debridement under General Anesthesia along with optimization of systemic co-morbidities.
Our treatment protocol included administration of two to three doses of intravenous amphotericin B 200 mg (ATB) each preoperatively, followed by aggressive surgical debridement under strict glycemic control. This was followed by administration of intravenous ATB till a cumulative dose of 3–5 g, depending upon the extent of the disease as well as the resolution of initial indicative findings on imaging and reconstitution of host immune system. Strict daily monitoring of renal parameters and serum electrolytes was done. Azole derivative, Posaconazole was used for step down or salvage therapy. Patients were discharged on Oral Posaconazole delayed release tablets (300 mg BD for day 1, followed by 300 mg OD) for 3 months. Repeat scans were done in case of any new symptoms or at the end of 3 months to rule out any recurrence of disease.
The QOL was measured 1 month after debridement using OHIP-14; and the prosthetic rehabilitation of the surgical defect was done using temporary obturator made with acrylic resin material after taking an impression with addition silicone elastomeric impression material and making a master cast. The OHIP-14 was measured again after 3 months of obturator use to evaluate any improvement in QOL after obturator use.
Objective of the Study
To evaluate the QOL of the patients using oral health impact profile 14 (OHIP-14), which measures the social impact of oral disorders on individual’s overall well-being. The assessment of an individual’s quality of life through OHIP-14 encompasses seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Within each domain, the mean value was computed based on responses to two interconnected questions. A higher score indicated a lower level of health for the patient. The QOL of the patients was measured post-surgical debridement at 1 month (T1) and at 3 months post obturator use (T2).
To describe the demographic profile, risk factors, clinical presentation, diagnosis using radiology, microbiology, and histopathology, management, and treatment outcomes of CAM.
Statistical Analysis
To evaluate the quality of life (QOL) of 27 rehabilitated patients using obturators, we conducted inferential statistics by comparing OHIP-14 scores at two distinct time points: T1, which represented the post-surgical debridement phase, and T2, signified the QOL assessment at 3 months post-obturator use. Paired t-tests were employed to evaluate whether a statistically significant difference existed between T1 and T2 scores. This analysis was executed with a predetermined significance level (alpha) set at P < 0.05. IBM SPSS software, Version 25,was utilized for conducting these statistical analyses.
Results
A total of eighty patients were included in the study with mean age being 46.38 years (23–76 years). A total of 65 were male patients (81.2%). The flowchart of the study is described in Fig. 1. The baseline demographic data, associated comorbidities, and the management of the patients during COVID-19 infection is described in Table 1.
Fig. 1.
Flowchart of the study
Table 1.
Baseline characteristics
| Characteristics | N |
|---|---|
| Age | 46.38 years |
| Gender (Male: Female ratio) | 4.32:1 |
| RT PCR Covid 19 positive | 57 (71.25%) |
| HbA1c | 10.8% |
| Occupation | |
| Labourers | 10 (12.5%) |
| Farmers | 20 (20%) |
| Private employee | 21 (26.3%) |
| Government servant | 6 (7.5%) |
| House wife | 14 (17.5%) |
| Shopkeepers | 6 (7.5%) |
| Carpenter | 3 (3.8%) |
| Latency period from Covid19 diagnosis to development of CAM | Mean 34.36 days |
| CT severity score | 4.363 |
| Comorbidities | |
| Diabetic | 24 (30%) |
| Hypertensive | 13 (16.25%) |
| Management during Covid19 infection | |
| Steroid treatment | 48 (60%) |
| Mean duration of steroid treatment | 4.163 days (2–25 days) |
| Antiviral drugs | 58 (72.5%) |
| Antibiotic drugs | 55 (68.8%) |
| Supplemental oxygen | 61 (76.3%) |
The mean duration of latency period from the time of diagnosis of COVID-19 infection to the development of CAM was 34.36 days (range 10–90 days). Diabetes mellitus (mean glycosylated hemoglobin 10.8%) was the most common comorbidity (30%). 60% of the patients received steroid treatment and 76.3% supplemental oxygen during their management of COVID-19 infection. The clinical presentations of the patients depicted that most of them complained of sudden onset tooth pain and mobility (Table 2), with underlying avascular bone (Fig. 2).
Table 2.
Clinical presentations
| Clinical features | n (out of 80) |
|---|---|
| Tooth pain | 28 (35%) |
| Tooth mobility | 21 (26.3%) |
| Gingival swelling | 6 (7.5%) |
| Infraorbital paraesthesia | 6 (7.5%) |
| Facial swelling with pain and headache | 9 (11.25%) |
| Ophthalmalgia and proptosis | 6 (7.5%) |
| Sinus opening with pus discharge, nasal obstruction | 4 (5%) |
Fig. 2.
Fungal osteomyelitis involving the maxilla (blue arrow)
The extension of the CAM was evaluated by CECT PNS imaging (Table 3), Maxillary sinus being most commonly involved sinus (98.75%) (Fig. 3). Orbital involvement was seen in 20% cases, and intracranial extension in 8.75% cases.
Table 3.
Diagnosis using radiology, microbiology, and histopathology
| Parameters | n (out of 80) |
|---|---|
| Site involved (based on CT imaging) | |
| Alveolus | 58 (72.5%) |
| Palatal bone | 54 (67.5%) |
| Maxillary sinus | 79 (98.75%) |
| Ethmoid sinus | 41 (51.25%) |
| Sphenoid sinus | 21 (26.25%) |
| Bony erosion of anterior wall of maxillary sinus | 77 (96.25%) |
| Hypertrophied turbinate | 31 (38.75%) |
| Orbital involvement | 16 (20%) |
| Intracranial extension | 7 (8.75%) |
| KOH wet mount (positive) | 62 (77.5%) |
| Fungal culture (positive) | |
| Rhizopus species | 30 (37.5%) |
| Mucor species | 7 (8.75%) |
| Concomitant aspergillus | 9 (11.25%) |
| Concomitant candida species | 5 (6.25%) |
| Histopathology (positive) | 66 (82.5%) |
Fig. 3.
Contrast Enhanced Computed tomography (a) Axial section showing mucosal thickening in bilateral ethmoid (blue arrow) and sphenoid sinus (orange arrow) (b) Axial section showing erosive bony changes in relation to maxillary alveolus (red arrow) (c) Coronal section showing mucosal thickening in relation to bilateral ethmoid sinus (blue arrow), left maxillary sinus (yellow arrow), and bony erosive changes i.r.t left floor of orbit (green arrow), and left maxillary alveolus (red arrow)
The direct tissue KOH wet mount preparation was positive (non-septate/pauci-septate, ribbon like hyphae) for fungal elements (Fig. 4. A) in 62 patients (77.5%) as seen in Table 3. Histopathological examination revealed Fungal osteomyelitis (Fig. 4. B), due to mucormycosis in 66 patients (82.5%).
Fig. 4.
(a) KOH mount showing broad hyaline aseptate right-angle branched (arrow marked) fungal hyphae (Mucor morphology) (b) Histopathology showing aseptate, foldable ribbon like fungal hyphae with right angle branching
The surgical management of the 80 patients included aggressive surgical debridement (Table 4). All patients were followed up for a minimum of 9 months, during which 12 patients (15%) underwent re-debridement due to recurrence of the disease. No other patients showed signs of recurrence of disease (Table 4). No other adverse events were seen.
Table 4.
Management and treatment outcome of CAM
| Parameter | n (out of 80) |
|---|---|
|
Management Infrastructure maxillectomy |
45 (56.25%) |
| Subtotal maxillectomy | 19 (23.75%) |
| Total Maxillectomy with zygoma debridement | 16 (20%) |
| Maxillary sinus debridement | 80 (100%) |
| Ethmoidal sinus debridement | 41 (51.25%) |
| Sphenoid sinus debridement | 21 (26.25%) |
| Orbital Exenteration | 6 (7.5%) |
| Debridement of anterior table of the frontal bone | 3 (3.75%) |
| Skull base debridement | 4 (5%) |
| Treatment outcomes | |
| Stable | 62 (77.5%) |
| Re-debridement | 12 (15%) |
| Orbital exenteration | 6 (7.5%) |
| Mortality | 0 |
The quality-of-life post debridement at 1 month (T1) and after 3 months of obturator use (T2) was measured using OHIP-14. The total OHIP-14 scores at T1 were 49.55 ± 9.822, and at T2 were 25.5 ± 6.809. The mean score of each of the 7 domains and the total scores decreased significantly from T1 to T2. The comparison of the mean scores of each of the 7 domain and the total score showed statistically significant difference from T1 to T2 (P < 0.001) (Table 5).
Table 5.
OHIP-14 scores post-surgical debridement (T1) vs. post 3 months obturator use (T2)
| Domains | T1 Mean ± SD | T2 Mean ± SD | P |
|---|---|---|---|
|
Functional limitation 1.Trouble pronouncing words 2.Worsened chewing capability Subtotal |
3.55 ± 0.999 3.65 ± 0.813 7.2 ± 1.609 |
1.65 ± 0.875 1.55 ± 0.759 3.2 ± 1.240 |
< 0.001 < 0.001 < 0.001 |
|
Physical pain 1. Painful aching 2. Uncomfortable to eat Subtotal |
3.65 ± 0.875 3.70 ± 0.865 7.35 ± 1.694 |
1.60 ± 0.754 2.05 ± 0.999 3.65 ± 1.531 |
< 0.001 < 0.001 < 0.001 |
|
Psychological discomfort 1. Self-conscious 2. Tensed Subtotal |
3.95 ± 0.887 3.80 ± 0.951 7.75 ± 1.682 |
2.05 ± 0.999 1.75 ± 0.967 3.8 ± 1.642 |
< 0.001 < 0.001 < 0.001 |
|
Physical disability 1. Unsatisfactory diet 2. Interrupt meals Subtotal |
3.45 ± 0.945 3.65 ± 0.875 7.1 ± 1.683 |
1.75 ± 1.118 1.95 ± 1.099 3.7 ± 1.949 |
< 0.001 < 0.001 < 0.001 |
|
Psychological disability 1. Difficult to sleep 2. Been embarrassed Subtotal |
3.40 ± 1.046 3.70 ± 0.801 7.1 ± 1.714 |
1.45 ± 0.826 2.15 ± 1.226 3.6 ± 1.314 |
< 0.001 < 0.001 < 0.001 |
|
Social disability 1. Been irritable 2. Difficulty to do job Subtotal |
3.70 ± 0.801 3.35 ± 0.988 7.05 ± 1.538 |
1.95 ± 1.099 1.75 ± 0.910 3.7 ± 1.559 |
< 0.001 < 0.001 < 0.001 |
|
Handicap 1. Felt life is less satisfying 2. Totally unable to function Subtotal |
3.45 ± 0.999 2.55 ± 0.759 6 ± 1.451 |
2.20 ± 0.834 1.65 ± 0.671 3.85 ± 0.988 |
< 0.002 < 0.001 < 0.001 |
| Total | 49.55 ± 9.822 | 25.5 ± 6.809 | < 0.001 |
Strongly disagree − 1, Disagree − 2, Undecided − 3, Agree − 4, Strongly Agree − 5
Discussion
The upsurge of CAM during the past 2 years has led to significant morbidity and mortality. The radical/aggressive debridement leads to prosthetic defect and affects the quality of life significantly. The rehabilitation of these defects using the obturators have significantly enhanced the overall quality of life of these patients. The study also described the surgical and the medical management of the COVID-19 associated Mucormycosis (CAM), which is an angio-invasive, opportunist fungal infection, with a prevalence of 0.14 cases per 1000 [10].
The fungal infection can involve nasopharynx and paranasal sinuses, orbit, CNS, lung (pulmonary form), gastrointestinal tract, skin (Cutaneous form), Renal and Hepatic system, with Rhino-orbito-cerebral mucormycosis (ROCM) being the most common involved site [11].
Uncontrolled diabetes is the most common predisposing factor to CAM in our tertiary care center 24/80 patients (30%). The presence of diabetes mellites significantly increases the odds of ROCM infection by 7.5 times (Odds ratio 7.55, P 1⁄4 0.001) [12]. The increased expression of GRP78 (glucose-regulated protein) and CotH3 (a protein kinase expressed in the germinations of Rhizopus oryzae) in the nasal epithelial and endothelial cells, acidic environment (diabetic ketoacidosis), with augmented availability of iron for the Mucorales make diabetes and DKA the most common risk factor for the mucormycosis (54–76%) [13].
Our patients were predominantly male (4.32:1 ratio), 30% of whom were diabetic with mean HbA1c level of 10.8%. 48/80 patients received corticosteroid treatment during their COVID-19 infection, with mean duration of steroid treatment being 4.163 days. Steroids cause defect in function of the neutrophils and macrophages, thereby downregulating the expression of (TNF)-α, IL-1β, IL-6, IL-8, and IL-12 eventually leading to immunosuppression [14]. There have been few documented case reports of CAM in diabetic patients even with a short course therapy (5–14 days) [15].
The RECOVERY TRIAL has documented reduced 28 days mortality in COVID-19 infected patients who received 6 mg dexamethasone for 10 days along with either invasive mechanical ventilation or oxygen alone versus those receiving no respiratory support [16], however the authors cautioned against the use of high dose steroids.
68.8% of our patients reported with injudicious use of antibiotics during COVID-19 infection. The nasal microbiome inhibits the adhesion and invasion of Rhizopus, preventing the fungal growth and colonization. However, the indiscriminate use of antibiotics alters this microflora, thus promoting breeding grounds for the Mucorales [14, 17].
The clinical presentation, Diagnostic Nasal Endoscopy (DNE), radiology adjuvants (CECT/CEMRI), microbiology and histopathology help in diagnosing Mucormycosis. The other advanced adjuvants used for tissue diagnosis include Polymerase chain reaction (PCR) based molecular identification of DNA sequencing based on bar codes 18 S, ITS,28s, rDNA, MALDI-TOF, immunohistochemistry, in-situ hybridization [18].
The 20% KOH wet mount was positive in 62 of 80 cases, showing broad hyaline aseptate right-angle branched fungal hyphae. The histopathology is the most sensitive diagnostic modality of mucormycosis [19], which shows septate, foldable ribbon like fungal hyphae with right angle branching and necrosis background with angioinvasion. Few concomitant infections of aspergillosis (11.25%) and candida (6.25%) were also documented in the study.
The extent of adjacent hard and soft tissue evaluation is best assessed by CECT PNS with orbit and brain, and/or CEMRI imaging. The CECT scan helps in early detection of the osseous erosive/degenerative changes, aiding the surgeon in early debridement, thereby preventing infection of the avascularized bone [20]. The present study showed alveolus as the most common bone involved (72.5%); among the paranasal sinuses the maxillary sinus was most frequently involved (98.75%) followed by the ethmoid (51.25%) and the sphenoid (26.25%). The inhalation of the fungal spores seeds them into the paranasal sinus, which spread inferiorly to the palate, laterally to the cavernous sinus, the orbit (20% in the study), and intracranial spread (8.75%) by direct extension (via cribriform fossa or orbital apex) or by angio-invasion [20]. The CAM is associated with significant mortality and morbidity rates, a 3–6 days delay in treatment can double the 30 days mortality rate from 35 to 66% [21]. Also, the intracranial extension accounts to fatality of as high as 90% [22].
The management includes elimination of the underlying risk factors including Diabetes control, tapering/discontinuation of steroid dose, altering the immunosuppressants drugs. Depending on the disease progression, surgical management involves excision and aggressive debridement of the involved tissues [23] till fresh bleeding and healthy soft tissue/bone is seen, along with FESS of the involved/diseased sinus. The aggressive surgical intervention reduces the fungal spores load and it also helps in better penetration of the antifungal drug instituted. Extended FESS with maxillectomies and radical debridement has proven to have better surgical outcomes with lower recurrence rates [24]. Antifungal therapy should be instituted at the earliest diagnosis of mucormycosis. Liposomal Amphotericin B 10 mg/kg/day (ATB) is the drug of choice in fungal osteomyelitis [25], it is given in cumulative dose of 3–5 g as per the institutional protocols till the resolution of the disease. This formulation is preferred over the conventional ATB as it is least nephrotoxic [26]. Oral Posaconazole is used as a step down/salvage therapy, with loading dose of 300 mg BD followed by 300 mg OD for 3 months.
Liposomal ATB is associated with hypokalemia, nephrotoxicity, hyponatremia, and hepatotoxicity [25]; thus, strict monitoring of renal, hepatic parameters, blood glucose levels, and serum electrolytes levels are required.
Patients treated with medical and surgical management had significant increase in chances of survival compared to those treated with only antifungal agents. In the study by A. Patel et al., they compared the 90 days mortality in combined surgical and medical management group vs. the medical management alone, the time to death was significantly lower in patients who opted for only medical management (P = 0.0001) [27].
The aggressive surgical debridement affects the quality of life of the patients significantly. The rehabilitation of the post maxillectomy defect status can be done with surgical reconstruction or prosthetic rehabilitation. The large size defects, risk of recurrence, and patients’ negative consent for invasive reconstruction limits the surgical reconstruction options [28]. Prosthetic rehabilitation with temporary obturator, and definitive prosthesis with zygomatic implants and patient specific implants help in restoring the form, function, and aesthetics of the patients.
Removable prosthesis such as surgical obturators are most commonly used in post maxillectomy defects; they are safe, cost-effective, faster alternative with satisfactory outcomes. These devices restore speech by reducing hypernasality, facilitate oral feeding, minimize the nasal regurgitation of food or liquid, assist in maintaining proper oral hygiene, and allow for convenient inspection of maxillectomy defects to monitor any potential recurrence.
The results of our study show statistically significant improvement in QOL across all the variables, functional limitation (P < 0.001), physical pain (P < 0.001), psychological discomfort (P < 0.001), physical disability (P < 0.001), psychological disability (P < 0.001), social disability (P < 0.001), and handicap (P < 0.001) post 3 months of obturator use; and is consistent with the study by Kazuyuki Yusa et al. [29].
However, the absence of alveolar support, shallow vestibular depth, cantilever of forces in the anterior segmental defects with posterior abutments, loss of keratinized gingival tissue, and the overall weight of the obturator compromises its retention making its use challenging for the patients [30].
The definitive rehabilitation of the surgical defects using Zygomatic Implants or Patient Specific Implants provide an additional versatile prosthetic rehabilitation option with minimum surgical morbidity and greater functional and esthetic outcome to the patients.
These implants allow for early restoration with obturator prosthesis by providing high primary stability and anchorage for the prosthesis [31]. Additionally, they contribute positively to the patient’s psychological well-being by reducing the stress and anxiety. The drawbacks associated with zygomatic implants include issues such as failure to properly Osseo-integrate, positioning errors, the potential for oronasal communication to develop, and the financial strain placed on patients [31].
The rehabilitation of the surgical defects in 27 patients with the temporary obturators (Fig. 5) have shown to significantly improve their function, aesthetics, and social well-being. The initial surge of COVID-19 infections resulted in a huge financial crisis for patients below the poverty line, mainly due to the substantial expenses associated with Liposomal Amphotericin B and Posaconazole drugs. The additional economic burdens related to rehabilitation, particularly with Zygomatic/Patient-specific implant supporting prostheses, contributed to wider acceptance of obturators among these patients.
Fig. 5.
(a) Surgical defect post left side maxillectomy in Rhino-orbito-maxillary Mucormycosis (b) Prosthetic rehabilitation of the maxillectomy defect using temporary obturator
The QOL of the patients rehabilitated with temporary obturators demonstrated significant improvement through OHIP-14 after 3 months of obturator use. Thus, early prosthetic rehabilitation of the post-maxillectomy surgical defects in CAM patients with obturators can greatly restore their oral function and overall quality of life.
Our study has a few strengths as well as limitations. This study is one of the pioneers that has focused on the quality-of-life post debridement, as being disease free is the main goal during surgery, but it worsens the aesthetics as well as functional outcome. Placement of temporary obturators is less expensive and has shown significant improvement. However, the definitive rehabilitation of the defects requires Zygomatic/Patient specific implant supported prosthesis. The study design minimized the recall bias, and the baseline parameters were collected to address the risk factors. The limitations of the study included limited sample size and shorter follow up period.
Conclusion
A multidisciplinary approach is required in combating the menace of CAM. Early and prompt diagnosis, controlling the predisposing and risk factors, combined aggressive surgical and medical management, and early rehabilitation of the surgical defect with obturator leads to better outcomes; thereby reducing the morbidity, mortality and improving the overall quality of life of the patients.
Acknowledgements
We would like to express our gratitude to the Department of Dentistry, Otorhinolaryngology, Microbiology, Pathology and Lab Medicine, General Medicine, and Diagnostic and Interventional Radiology for collaborating in order to provide excellent patient care.
Author Contributors
All authors contributed to the study conception and design. Material preparation was done by Dr Ankita Chugh, and Dr Akhilesh Kumar Pandey. Data collection was done by Dr Amanjot Kaur, Dr Shubham Gaur, Dr Aakash Kohli. Data analysis was done by Dr Abhishek Anil. The first draft of the manuscript was written by Dr Akhilesh Kumar Pandey, and all authors commented on previous versions of the manuscript. The following authors were involved in patient care: Dr Ankita Chugh, Dr Amit Goyal, Dr Kapil Soni, Dr Vidhu Sharma, Dr Deepak Kumar, Dr Sanjeev Misra. The following authors were involved in diagnostic intervention: Dr Vidhi Jain, Dr Taruna Yadav, Dr Poonam Elhence; and Dr Ankita Chugh gave the final approval of the manuscript:
Funding
The authors have no relevant financial or non-financial interests to disclose.
Declarations
Ethical Approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee (AIIMS/IEC/2021/3547), dated 18/06/2021.
Consent to Participate
Informed consent was obtained from the patient.
Consent to Publish
The authors affirm that the patient provided informed consent for the publication of the images.
Conflict of Interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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