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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 3  |  Page : 187-191

Effect on quality of life and psychosocial issues of patients with maxillofacial fractures in rural setting


Department of Oral Maxillofacial Surgery, School of Dental Sciences, Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Date of Submission19-Sep-2020
Date of Acceptance13-Jan-2021
Date of Web Publication12-Jul-2021

Correspondence Address:
Laxmi Sureshkumar
Pulickal House, B.O.C Road, Shastri Lane, Perumbavoor, Ernakulam - 683542, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_165_20

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  Abstract 


Background: Maxillofacial injuries are a serious public health problem and are often associated with severe morbidity, disfigurement, and psychological problems. The life of the patient often takes a turn for the worst and he/she has to face many difficulties moving forward. Analysing and determining the quality of life of such cases will give us a better understanding and insight and will further improve the care and treatment of the patients. Aims: Analyse and evaluate the psychosocial impact of maxillofacial fractures on individuals who were healthy pre-trauma. Material and Methods: The participants are the 30 patients with facial trauma reported to the Department of Oral and maxillofacial surgery of the School of Dental Sciences and Krishna hospital, Karad, who will be required to undergo surgical treatment (i.e., Open reduction and internal fixation for facial fractures) and are willing to participate in this study. All 30 patients were given a questionnaire form modified from the pre-existing Acute Stress Disorder Scale, Oral Health Impact Profile questionnaire and Posttraumatic Diagnostic Scale, which includes questions regarding speech, sense of taste, pain, uncomfortable eating, orientation, tension, unsatisfactory diet, interrupted meals, difficulty to relax, embarrassment, irritability, occupational dysfunction, etc. during their 15 days follow up appointment post-surgery. This obtained data was then analysed and was subjected to appropriate statistical analysis. Result: In a study sample of 30 patients, 8% were found with intense psychosocial issues due to trauma, 14% had a moderate, and 18% had mild issues that affected the quality of their life post-trauma. Conclusion: The study shows a great need for psychological screening and evaluation of patients with maxillofacial injury/fractures due to trauma to improve the patient's physical and psychological recovery.

Keywords: Acute Stress Disorder Scale, disfigurement, improve, maxillofacial injuries, morbidity, Oral Health Impact Profile, posttrauma, Posttraumatic Diagnostic Scale, psychological problems, psychosocial issues, public health problems, quality of life, rural


How to cite this article:
Sureshkumar L, Patil P, Iyer Y. Effect on quality of life and psychosocial issues of patients with maxillofacial fractures in rural setting. Indian J Dent Sci 2021;13:187-91

How to cite this URL:
Sureshkumar L, Patil P, Iyer Y. Effect on quality of life and psychosocial issues of patients with maxillofacial fractures in rural setting. Indian J Dent Sci [serial online] 2021 [cited 2021 Sep 20];13:187-91. Available from: http://www.ijds.in/text.asp?2021/13/3/187/321174




  Introduction Top


Every 30 s of the day someone dies on the world's roads. Annually over 1 million people die and over 25 are injured or permanently disabled from road traffic injuries.[1] The face being the most exposed part of the body, is particularly prone to trauma. Trauma to the facial region causes injuries to skeletal components, dentition as well as soft tissues of the face.[2],[3],[4] The primary cause of maxillofacial fractures throughout the world is road traffic accidents and assaults; such injuries are increasing in frequency and severity because of the heavy reliance on road transportation and increasing trends of violence.[5],[6]

Maxillofacial trauma was identified by Shepherd[7] as an important target for research because of its potential for both physical and psychological disabilities.[8] They are often associated with morbidity, disfigurement, and psychological problems. The human face is a vital component of one's personality and body image, and a visible disfigurement can have a significant psychological impact upon the individual concerned.[9],[10] Although medical treatment may repair the broken bones, many of the patients continue to be at a risk of re-injury or poor psychological outcomes because they lack proper evaluation of their mental health posttrauma.[11],[12]

The literatures on maxillofacial trauma are largely confined to reporting the epidemiology of these injuries or to articulating practical guidelines. The current practice of viewing these injuries only within a surgical context can and do affect the health outcomes.[12],[13],[14],[15] In terms of psychological significance, disfigurement in the facial area is likely to produce extreme emotional distress pertaining to social functioning. Even minor lacerations can produce elevated anxiety and social problems.[16],[17]

Posttraumatic stress disorder (PTSD) symptoms produced by anxiety and depression have adverse effects on body image, quality of life, and self-esteem of the patient, and it is often difficult to predict the course of adaptation in many of the patients.[18] Unless recognized and treated, posttraumatic psychological problems can become chronic.[8] It is important, therefore, that the surgeons be aware that the outcome of their work is determined not only by their surgical skills but also by a range of social and psychological factors.[10],[19]

Until recently, our understanding of impact of trauma has derived mainly from the study of survivors of major disasters and wars with PTSD.[8],[20] Given the sparse literature, the need persists for investigation into the psychological responses and management needs of patients with facial injury persisting after the trauma.[17]

Although the interest has been steadily growing in the study of psychological consequences of exposure to traumatic events, any literature on the psychosocial impact of maxillofacial trauma in a developing county such as India is negligent. With a dense population and increasing frequency of road traffic accidents, it is imperative that studies be conducted in various parts of India.

The objective of this study was to evaluate the social and psychological impact of facial trauma on previously healthy individuals admitted to the Department Oral and Maxillofacial Surgery in School of Dental Sciences, Krishna Charitable Hospital and Research Centre, Karad, Maharashtra.


  Materials and Methods Top


A retrospective analytical study was conducted among 30 patients with facial trauma reported to the Department of Oral and Maxillofacial Surgery of the School of Dental Sciences and Krishna Charitable Hospital and Research Centre from the month of August 2018. The study protocol was reviewed by the Institutional Ethical Committee of Krishna Institute of Medical Sciences and Hospital and was granted ethical clearance (protocol number 0295/2017-2018), and informed consent of participants was taken.

Inclusion criteria

  1. All the patients included will be in the age group ranging from 18 to 65 years
  2. Patients with isolated facial fractures
  3. Patients who are willing to participate in the study
  4. Patients with normal psychological status pretrauma.


Exclusion criteria

  1. All the patients not within the age range of 18–65 years are excluded
  2. Patients with multiple fractures are excluded
  3. Noncooperative, unwilling patients are excluded
  4. Patients with systemic diseases
  5. Patients with abnormal psychological status pretrauma.


Questionnaire

The questionnaire form was modified from the preexisting Acute Stress Disorder Scale (ASDS), Oral Health Impact Profile questionnaire, and Posttraumatic Diagnostic Scale, which include questions regarding speech, sense of taste, pain, uncomfortable eating, orientation, tension, unsatisfactory diet, interrupted meals, difficulty to relax, embarrassment, irritability, and occupational dysfunction during their 15-day follow-up appointment postsurgery.

ASDS is a new diagnostic category included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)[21] in recognition of the high levels of distress that individuals can experience in the acute phase of traumatic experience.[17],[22] Evidence of the convergent and predictive validity of the ASDS has been presented at Bryant and Harvey.[23]

The OHIP questionnaire is one of the most commonly used instruments; it has been used in various studies across different cultures and sociodemographic profiles. It was developed in order to provide a comprehensive measurement of the dysfunction, discomfort, and disability associated with oral conditions as reported by the individual.[24],[25],[26]

The Posttraumatic Diagnostic Scale is a brief self-reporting questionnaire developed for the diagnostic screening and assessment of the severity of PTSD.[27] It is based on the DSM-V.

Questions

  1. Have you experienced a life-threatening event that caused intense fear or helplessness
  2. Do you have repeated distressing memories or dreams about that incident
  3. Do you have intense physical and/or emotional distress when you are exposed to the things that remind you of the event
  4. Do you avoid thoughts, feelings, or conversations the event
  5. Do you avoid activities and places which remind you of the event
  6. Have you lost interest in any significant activity of your life
  7. Do you feel detached from other people
  8. Do you have problems sleeping
  9. Do you feel irritable or experience outbursts of anger.
  10. Do you have trouble concentrating
  11. Do you experience an exaggerated startle response
  12. Have you experienced changes in sleeping or eating habits
  13. Have you had problems saying some words
  14. Do you feel that the taste of food has worsened
  15. Do you feel uncomfortable eating any food
  16. Do you feel stressed
  17. Do you find it hard to relax
  18. Do you feel embarrassed facing people
  19. Do you find it difficult to carry out your daily activities
  20. Do you feel your life in general has worsened


    1. No
    2. Rarely
    3. Sometimes
    4. Yes.


Statistical analysis

The variables were computed into Tableau and descriptive variables were tabulated as shown in [Figure 1] and [Figure 2].
Figure 1: Result obtained after tabulating the data from the questionnaire

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Figure 2: Frequency of the evaluated psychosocial impact on the patients is presented

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  Results Top


The study, which progressed from August 2018 to July 2019, involved 30 patients admitted to the Department Oral Maxillofacial Surgery at the School of Dental Sciences and Krishna Hospital who met the inclusion criteria.

These patients were evaluated 15 days post-surgery, and the results obtained from the questionnaire were tabulated and analyzed as shown in [Figure 1].

The frequency, as shown in [Figure 2], of the evaluated psychosocial impact on the patients was calculated from the data analyzed from [Figure 1]. Eight percent of the patients had an intense psychological and social impact from the trauma; 14% of the patients had a moderate level of impact, 18% had a mild level of impact, and 60% had no/minimal psychosocial effect due to the maxillofacial trauma.


  Discussion Top


In this study, we sought to understand the effect on the psychological, social, and quality of life of patients with maxillofacial fractures in a rural setting such as the Satara district.

During the study period, out of all the patients, 30 patients who met the criteria for this particular study were selected and evaluated. This comprised patients with isolated fractures of the zygomatic bone, nasal fractures, mandibular fractures, and Le Fort fractures. Not all the patients admitted during the study period could be included in the study as they did not meet the inclusion criteria.

Traumas generally modify the physical and psychiatric well-being of the patients in unexpected ways. When the patients were evaluated for the study, according to the data obtained from [Figure 2], 8% required immediate psychological intervention, counseling, and treatment while 32% required a psychological evaluation regarding the effect on their psychology, social, and quality of life with eventual appropriate treatment. These patients had a generally positive response to the question of irritability; startlement; lack of sleep; uncomfortableness with the discussion and thought of the incident, the disfigurement/scar; embarrassment; and their inability to relax in a normal environment.

These findings may act as a sequela toward depression, PTSD, and acute stress disorder among 40% of the patients studied. As manifest by the traumatic stress literature, injury can disable people in terms of their physical, mental, and social functioning. Poor mental health seems to be not only one of the common disabling sequelae of traumatic injury but also the outcome that may hold the most promise for modification by appropriate psychosocial intervention.[28] Fauerbach et al. emphasizing the need to assess, identify, and treat psychological issues stated that psychological needs delay the rate of recovery of both physical and psychological health and function.[29]

Trauma research is increasingly clarifying factors predictive of posttraumatic psychological disturbance. This study identifies some factors that should be incorporated within a comprehensive initial assessment, such as psychological status and the resultant impact on their social life. This reflects the complex interaction of factors relating to the injury, the patient, and the circumstances in the etiology of psychological reactions.

In many cases, patients with facial injury may express unhappiness due to facial appearance after facial trauma leading to social isolation. Some facial trauma studies have found that the degree of anxiety is directly proportional to the magnitude of injury and the scar it leaves. Other studies have indicated that the patient's perception of their facial disfigurement is an important factor in development of depressive and anxiety symptoms.[16],[30] In addition, clinical assessment of the severity of injury is not predictive of future PTSD. Many patients do not perceive their injuries to be life threatening and yet psychological distress maybe high. It is also important to identify early those affected due to a combination of factors provoking posttraumatic reactions.[31],[32],[33],[34]

Given the high rates of unrecognized, untreated psychosocial problems in patients presenting with maxillofacial injury, using the acute care visits as an opportunity to screen for psychosocial problems will likely increase the detection of patients with behavioral disorders and high-risk behaviors that precipitated the injury which could interfere with a comprehensive recovery. Psychosocial screenings of trauma patients followed by referral to mental health services for those identified with psychosocial dysfunction may result in improved outcomes.

The recognition of the potential for posttraumatic reactions after maxillofacial trauma could have implications for resources and practice. If such reactions are treated early and effectively, noncompliance with treatment for facial injury may be limited and recovery rates may be improved.

The underlying premise is that by viewing patients in a broader context at the initial encounter, clinicians will be able to see beyond the physical injury to include consideration of equally pernicious psychosocial factors that can prevent patient recovery or set the stage for recurrent injury. Innovative cost-effective programs that can integrate medical and psychological care are especially necessary. Interventions such as motivational interviewing, a brief form of counseling designed to help individuals garner personal resources to promote positive behavior change which can be offered to patients within days of their facial injuries, may be especially important in improving long-term outcomes.

Limitations

  • Understanding and psychology of patients in urban and rural areas varies
  • Wider sample size will be required to further the study as well as comparison with data from different hospitals.



  Conclusion Top


Essentially, this attempt of the study was meant for addressing the core factors which relate to the psychosocial issues that may develop due to traumatic injuries of patients on the point that human beings are a psychosomatic pack.

Although there is a high risk of psychological distress and resultant impact on the quality of life of patients with maxillofacial trauma, there is a severe lack of screening for such cases in many hospitals in India.

Clinical Implications - the surgeons should be trained about behavioral issues, easily assessable guides for rapid screening of psychosocial problems as well as developing collaborative relationship with mental health professionals and social workers are important first steps toward integrating mental health services into the care of patients with facial injury.[12]

Ethical clearance

This research project was approved by The Institutional Ethics Committee of Krishna Institute of Medical Sciences, Deemed University, Karad, Maharashtra (Declared U/s 3 of USG Act, 1956 Notification No. F.9-15/2001 – U.3 of the Ministry of Human Resource Development, Govt. of India) – protocol number – 0295/2017-2018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]



 

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