217 General discussion 7 In patients with pharyngeal or laryngeal cancer who are primarily treated with RT, implantation may delay the onset of RT because the wound area must be healed before RT is started [20]. Since the introduction of intensity-modulated radiotherapy (IMRT), it has been possible to avoid high doses of RT to normal structures, including the anterior mandible [21]. With the development of volumetric modulated arc therapy (VMAT) and intensity modulated proton therapy (IMPT), even further dose adjustments are possible [19]. Therefore, delayed implantation may be preferred for patients treated with these current RT techniques. Implant placement after RT is primarily indicated in patients who have retention or chewing problems with their conventional prosthesis. However, in patients without functional problems who have received high doses of RT doses in the posterior portion of the mandible, implant placement should be considered. Despite the promising dose reduction in the tooth-bearing parts of the jaw, the dorsal parts of the mandible still receive relatively high RT doses in HNC patients [19, 22]. Placement of interforaminal implants offers the advantage that the prosthesis-bearing mucosa in these dorsal regions of the mandible can be unloaded to avoid soft tissue ulceration and necrosis. An exception should be made for patients who become edentulous during the removal of sources of infection prior to RT. A period of 10 to 14 days for wound healing until the start of RT is needed anyway, so implant placement does not cause any additional delay. However, in these patients, there is a potential risk of insufficient intermaxillary space remaining for prosthetic rehabilitation after RT because the jaws did not resorb. This can be assessed during the dental examination prior to RT. If one is to be expected, it is desirable to lower the alveolar process sufficiently before placing the implants. In our study, men appeared to benefit more from implants than women. While our differences between men and women may have been influenced by the fact that more women underwent surgery, other studies show differences between men and women in terms of prosthetic satisfaction [17, 23-25]. Consideration of gender differences in future research may contribute to better personalized care [26]. The Liverpool Oral Rehabilitation Questionnaire version 3 (LORQv3) In our initial study in Chapter 2, we encountered two limitations with our methods. First, we lacked an objective measure of masticatory performance, which we remedied in the studies in Chapter 4 by using the mixing ability test (MAT) [27]. In addition, available general QoL questionnaires, such as the EORTC
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