Abstract
Background
Radiotherapy of nasopharyngeal carcinoma (NPC) often delivers considerable radiation dose to the temporomandibular joint (TMJ). This may lead to radiation-induced trismus, which can have impact on the quality of life of post-radiotherapy (post-RT) patients. However, the exact cause of trismus and its relationship with dose has not been fully understood. This study aimed to evaluate the quantitative relationship between severity of post-RT trismus and TMJ doses and other patient characteristics. Through ultrasound examination, this study also aimed to identify factors affecting morphological changes of TMJ.
Methods
Ninety-seven NPC patients treated by radiotherapy for more than 4 years were recruited. The doses to both sides of the TMJ were calculated from the treatment planning system. The severity of trismus was assessed by measuring the maximum inter-incisal distance (MID) with a caliper. Ultrasonography examination of the both sides of TMJ was performed in both transverse and longitudinal directions. For the scan of each TMJ, the MID, irregularity of mandibular condyle and the echogenicity of the joint disc ligament and pterygoid muscles were assessed.
Results
The median age of all the subjects was 56 years, with median post-RT duration of 14 years and median mean TMJ dose of 64.15 Gy. The MID (median, 3.7 cm, range, 1.3–5.2 cm) demonstrated strong negative correlations with post-RT duration (r p = −0.441, p < 0.0005) and mean doses to the TMJ (r p = −0.262, p = 0.009). The negative relationship between TMJ dose and maximum disc thickness (MDT) was also found in transverse scan (r p = −0.218, p = 0.002). However, there is no significant relationship between TMJ dose and MDT in longitudinal scan, irregularity of condyle and echogenicity of pterygoid muscle.
Conclusion
In post-RT NPC patients, the severity of trismus, expressed in MID, increased with the doses to the TMJ and post-RT duration. In addition, the joint disc thickness decreased with increased dose to TMJ. Keeping a reasonably low TMJ dose in treatment planning and longer-term monitoring of the trismus of post-RT NPC patients are suggested to ensure their quality of life.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Chen YY, Zhao C, Wang J, Ma HL, Lai SZ, Liu Y et al (2011) Intensity-modulated radiation therapy reduces radiation-induced trismus in patients with nasopharyngeal carcinoma. Cancer 117:2910–6
Dijkstra PU, Huisman PM, Roodenburg JLN (2006) Criteria for trismus in head and neck oncology. Int J Oral Maxillofac Surg 35:337–42
Lee R, Slevin N, Musgrove B, Swindell R, Molassiotis A (2012) Prediction of post-treatment trismus in head and neck cancer patients. Brit J Oral Max Surg 50:328–32
Nguyen TD, Panis X, Froissart D, Legros M, Coninx P, Loirette M (1988) Analysis of late complications after rapid hyperfractionated radiotherapy in advanced head and neck cancers. Int J Radiat Oncol Biol Phys 14:23–5
Jen YM, Lin YS, Su WF, Hsu WL, Hwang JM, Chao HL et al (2002) Dose escalation using twice-daily radiotherapy for nasopharyngeal carcinoma: does heavier dosing result in a happier ending? Int J Radiat Oncol Biol Phys 54:14–22
Scott B, Butterworth C, Lowe D, Rogers SN (2008) Factors associated with restricted mouth opening and its relationship to health-related quality of life in patients attending a Maxillofacial Oncology clinic. Oral Oncol 44:430–8
Bensadoun RJ, Riesenbeck D, Lockhart PB, Elting LS, Spijkervet FK, Brennan MT et al (2010) A systematic review of trismus induced by cancer therapies in head and neck cancer patients. Support Care Cancer 18(8):1033–8
Caria N, Setton J, Zhang Z, Romanyshyn J, Hsu M, Branski RC et al (2010) Dosimetric correlation of the muscles of mastication with trismus in patients undergoing intensity modulated radiotherapy (IMRT) and chemotherapy for oropharyngeal carcinoma (OPC). Int J Radiat Oncol Biol Phys 78(3):S427
van der Molen L, Heemsbergen WD, de Jong R, van Rossum MA, Smeele LE, Rasch CR et al (2013) Dysphagia and trismus after concomitant chemo-intensity-modulated radiation therapy (chemo-IMRT) in advanced head and neck cancer; dose-effect relationships for swallowing and mastication structures. Radiother Oncol 106:364–9
Hsiung CY, Huang EY, Ting HM, Huang HY (2008) Intensity-modulated radiotherapy for nasopharyngeal carcinoma: the reduction of radiation-induced trismus. Br J Radiol 81(970):809–14
Lee N, Kramer A, Xia P. Phase II study of intensity modulated radiation therapy +/− chemotherapy for nasopharyngeal cancer. In RTOG 0225, 2005. https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0225. Accessed 3 Jul 2015
Wang CJ, Huang EY, Hsu HC, Chen HC, Fang FM, Hsiung CY (2005) The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer. Laryngoscope 115(8):1458–60
Sun X, Su S, Chen C, Han F, Zhao C, Xiao W et al (2014) Long-term outcomes of intensity-modulated radiotherapy for 868 patients with nasopharyngeal carcinoma: an analysis of survival and treatment toxicities. Radiother Oncol 110(3):398–403
Kaplan AS, Assael LA (1991) Temporomandibular disorders: diagnosis and treatment, 1st edn. W.B. Saunders, Philadelphia
Saintigny Y, Cruet-Hennequart S, Hamdi DH, Chevalier F, Lefaix JL (2015) Impact of therapeutic irradiation on healthy articular cartilage. Radiat Res 183(2):135–146
Tolentino EDS, Centurion BS, Ferreira LHC, de Souza AP, Damante JH, Rubira-Bullen IRF (2011) Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients. J Appl Oral Sci 19(5):448–54
Manfredini D, Guarda-Nardini L (2009) Ultrasonography of the temporomandibular joint: a literature review. Int J Oral Maxillofac Surg 38:1229–36
Conflict of interest statement
Vincent WC Wu has no conflict of interest. Michael TC Ying has no conflict of interest. SY Tam has no conflict of interest. Dora LW Kwong has no conflict of interest.
Authors’ contributions
Vincent WC Wu involved in study design, administration, data analysis and manuscript editing. Michael TC Ying involved in study design. SY Tam involved in data collection and analysis, drafting of manuscript. Dora LW Kwong involved in study design.
Consent and ethical statement
All patients gave their consent before joining the study. This study was approved by the local ethics committee and was performed in accordance with the ethical standards laid down in the Declaration of Helsinki. Informed consent was obtained from all subjects before the study.
Author information
Authors and Affiliations
Corresponding author
Additional information
An erratum to this article can be found at http://dx.doi.org/10.1007/s13566-016-0283-2.
Rights and permissions
About this article
Cite this article
Wu, V.W.C., Ying, M.T.C., Tam, S.Y. et al. A study of the factors affecting radiation-induced temporomandibular joint changes in post-radiotherapy nasopharyngeal carcinoma patients. J Radiat Oncol 5, 41–46 (2016). https://doi.org/10.1007/s13566-015-0215-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13566-015-0215-6