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Date: 16.10.

2012

THE RADIATION THERAPY PATIENT- TREATMENT PLANNING AND POST TREATMENT CARE

Sreeprabha G Mohan 2nd year PG student Dept of prosthodontics AECS Maaruti dental college

Introduction: Radiation is broadly used for diagnosis termed as diagnostic radiation and for therapy termed as therapeutic radiation. The therapeutic radiation is higher in intensity and delivers more grays of radiation to the tissues and to the health care personnel. Hence meticulous planning and high-level expertise is mandatory prior to selecting this modality. Surgery and radiotherapy are the two forms of treatment, which have a curative potential in orofacial cancer. These two modalities should be regarded as complementary rather than rivals in majority of cases. In some patients one or the other treatment modality may be preferable while in other patients both are needed to give the greatest chance of care. The prosthodontic treatment of head and neck cancer patients and its role in improving quality of life is well recognized. Prior to the early 1960s, the dentist or more frequently the prosthodontist, was engaged almost exclusively in dealing with the dental rehabilitation of the head and neck cancer patient who had undergone ablative surgery. With the increased use of radiation in the 1960s and cytoreductive drugs in the 1970s, dentistry was challenged with the task of developing treatment regimens for the oral complications associated with these forms of therapy. Although relatively large numbers of patients were treated, the role of the dentist in managing the oral complications associated with various cancer therapies was not completely understood. This was the case despite the fact that the National Institute of Health in a Consensus Development Statement estimated that as many as 400,000 patients developed oral complications as a result of cancer treatment. The same document noted that at a minimum, oral complications are painful, diminish the quality of life, and lead to significant compliance problems, often discouraging the patient from continuing treatment. As time has progressed, the oncology patients need for early and continual dental care has been proven to be beneficial by a number of clinicians and now recognized, for the most part, by the physician oncologist. Today the dental oncologist at most major cancer centers and the oncology oriented general dental practitioner in the private sector are valued participating members of oncology treatment teams. Definition: Radiotherapy, also called radiation therapy, is the treatment of diseases with ionizing radiation. Principles of radiotherapy: The radiotherapy is based on the basic premise that the fast growing and metabolically hyperactive cancer cell is more sensitive to the high-energy radiation as compared with the normal cell. This margin of safety is very marginal in some tissues hence the different modalities, different dose and time variations and different types of radiation deliveries. Goal of radiotherapy is to sterilize tumor and to preserve adjacent normal tissue. Ionizing radiation deposits energy that injures or destroys cells by damaging their genetic material, making it impossible for these cells to continue to grow. Lethal dose for normal and abnormal tissues is about the same Normal tissues have

greater ability to repair sublethal damage between doses, of radiation than neoplastic cells. The effects produced depend on factors like Oxygen Enhancement Ratio (OER), Linear Energy Transfer (LET), and Relative Biologic Effectiveness (RBE). OER = ratio of dose required to produce a given amount of damage in hypoxic condition to dose required to produce same amount of damage to oxygenated tissue. RBE = Ratio of dose of 250 kV X-rays to dose of test radiation required to produce equal amount of biologic effect LET = Energy transferred by the radiation along the path of travel. Sources of radiation: X-rays were the first form of radiation to be used to treat cancer. Depending on the amount of energy they possess, the rays can be used to destroy cancer cells on the surface of or deeper in the body. The higher the energy of the x-ray beam, the deeper the x-rays can go into the target tissue. Linear accelerators and Betatrons are machines that produce x-rays of increasingly greater energy. In the mid-1970s there has been much interest in the possible use of high-energy particles in radiotherapy. These particles include neutrons, protons, deuterons, stripped nuclei, and negative mesons. The radiotherapy is possible using the following types of radiation and charged particles. Gamma rays X-rays Charged particles Protons Electrons Negative - mesons Uncharged particles Neutrons RT with particulate radiation differs from photon radiotherapy in that it involves the use of fast-moving subatomic particles to treat localized cancers. Most particles (neutrons, pions, and heavy ions) deposit more energy along the path due to their mass. This is referred to as high linear energy transfer (high LET) radiation thus causing more damage to the cells they hit. Recent advance in radiotherapy research is the use of radio labelled antibodies to deliver doses of radiation directly to the cancer site (radio immunotherapy). Tumor-specific antibodies from certain tumor cells are attached to radioactive substances (radio labeling) and injected into the body, which actively seek out the cancer cells and destroy them by the cytotoxic action of the radiation. This approach can minimize the risk of radiation damage to healthy cells Types Of Treatment 1. Radical radiotherapy. Irradiation, which aims at cure, is termed as radical radiotherapy. Here the aim is the local and regional control of the primary and metastatic lymph nodes. It can only be achieved when all tumor cells are killed.

2. Palliative radiotherapy. The aim here is to relieve the symptoms caused by the cancer, thus improving the quality of life. This is usually indicated when there isnt a realistic likelihood of cure. 3. Multi modal treatment concepts. Here the treatment is a combination of surgery and radiotherapy. Postop irradiation is indicated when surgical wounds have healed and the interval should be kept to a minimum. In general radiotherapy the waiting period is between 2 to 4 weeks except in patients with delayed wound healing. Dosimetry The purpose of dosimetry is to evaluate the amount of energy absorbed by the tissues subject to radiation. Thus accurate treatment planning must consider: type of radiation : Energy : Penetration depth (Dmax) When a radiation beam penetrates tissue the dose decreases with depth of penetration after the maximum dose has been reached i.e. the Dmax or the penetration depth of the maximum dose. The region from the surface to the depth of the maximum dose is called the build up region. While the region beyond is called the fall off region. The depth dose curves are visualized on a plane running along the axis of the beam where points of equal dose are connected, as yielding curves known as Isodose curves. Various kinds of external beam radiation used are Single beam Multiple beam Single Beam: The penetration of a beam depends on its strength. Low energy xrays will result in the Dmax being superficial making it an excellent treatment modality for superficial lesions. With an increase in the energy the surface dose decreases, thus increasing the build up region, resulting in the Dmax being further away from the surface. Thus a highenergy beam has a skin sparring effect. Thus a choice of the beam is made depending on the type of tumor and its location. Multiple Beams-This is used when a tumor is large and is located deep. Thus it becomes necessary, in order to maximize tumor dose and to minimize the dose to normal tissues to use two or more beams. Beam configurations can vary from 2 simple opposed fields, angling fields, or 3 or more fields. Radiation Therapy Techniques Tele Therapy Also known as external beam irradiation, and is performed with the radiation source outside the patient. The beam penetrates the skin and is focussed to the treatment

area. Most commonly used sources are the Tele-cobalt machines emitting gamma rays and linear accelerators producing high energy X rays and electrons.

Brachy Therapy Here irradiation is delivered from a radiation source placed surgically in deep-seated tumors. Due to the proximity of the source the depth dose curves are very steep. This causes an uneven distribution even within a few cms. There is a fear of under dosage to the periphery, though there is greater sparring of the normal tissues. This may be used in conjunction with Tele therapy to boost the dosage to regional lymph nodes. They may be either permanent or temporary depending in the type of isotopes used. Radiation Effects on Tissues They can manifest as acute changes or chronic changes and the clinical sequelae are specific for each tissue .eg.-benign paralysis of motor nerves, atrophy of muscles , fibrosis in connective tissues. NTCP (normal tissue complication reaction) this is dependent on: Vol. of tissue irradiated. Dose administered. Fraction size. Interval b/w the two fractions. Individual and genetic factors. Cofactors (wound infection) Radiation injury can either be direct or indirect. Direct Injury Destroys or damages susceptible cells causing a loss or disruption of tissue function .eg. Salivary glands, mucosa, skin. Indirect injury This results from decreased vascularity and the subsequent changes in the tissue. These changes are classified to be based on responses that are Hypovascular Hypocellular Hypoxic Radiation tissue injury is not a quantitative measurement but a clinical assessment that explains the damage in terms of Total dose Dose rate Anatomic designs of radiation portals Clinical signs of injury. These signs may be acute, immediate, or latent in their presentation The short-term effects are: Mucositis Xerostomia

Concomitant change in oral microflora Loss of taste Increased sensitivity to spicy or strong tasting food. Long-term problems include: Reduced potential for bone healing and the risk of developing osteoradionecrosis (ORN) Permanent loss of salivary function Increased potential for dental caries Increased susceptibility to oral infections of candidiasis Trismus. The dental management of these patients is broadly divided into 1. Dental examination before radiation therapy and treatment plan 2. Dental management during radiation therapy 3. Dental management following radiation therapy Dental Examination before radiation therapy And Treatment Plan 1. Restorative procedures and dental extractions 2. Preradiation prosthodontic care 3. Postradiation prosthodontic care Restorative procedures and dental exactions Full mouth or panoramic radiographs are necessary as is a comprehensive clinical examination of the periodontium and oral soft tissues. An assessment of the patients oral hygiene is an important element in the initial examination. A dental prophylaxis and review of oral hygiene procedures should be examined carefully for dental caries. Definitive restorations should be placed and teeth considered no restorable or salvageable with endodontic therapy should be extracted. The required extractions must be accomplished expeditiously since a healing period of atleast 10 days to 3 weeks is essential before radiation treatment begins. Proposed extractions must be discussed with the radiation oncologist and an understanding reached regarding the time available for healing. When surgical removal of a tumor is planned prior to radiation teeth can be conveniently removed in the operating room at the time of tumor surgery thus ensuring an adequate healing period. It is generally advised that teeth be removed with minimal trauma and the extraction sited be closed primarily. Antibiotic coverage may improve the potential for healing in the case of diabetics and other medically compromised individuals. Periodically involved teeth exhibiting moderate to severe mobility should also be considered for removal. Some thought must be given to the long term prognosis of the teeth in question. The patients abi lity and willingness to perform all recommended oral hygiene procedures will also help determine which teeth can be maintained. In questionable situations, it is perhaps more prudent to err on the side of aggressive tooth removal, since extractions following radiation treatment will present an increased risk of osteoradionecrosis. It must also be remembered that wound healing will be compromised, and extensive periodontal surgery following radiation will be contraindicated. Frequently the dentist is faced with the decided to extract all remaining teeth. This should be tempered to some degree by the knowledge that the patient rendered

completely edentulous with no previous denture experience may find the process of adjusting to complete dentures a difficult one. Soft tissues within the radiated field will be easily irritated by the prosthesis retention. It is advisable to consider maintaining strategically positioned, periodontally sound teeth to be used as abutments for removable partial dentures or complete overdentures. Because irradiated bone loses the ability to remodel, radical alveolectomies must be considered for those patients who are candidates for removable prosthesis. Removal of tori and exostosis will help reduce soft tissue problems and improve the opportunity for prosthodontic success. Patients who present with partially erupted or impacted third molars are particular problems since a number of valid arguments can be made for and against extraction. Two issues are of importance in regard to the decision to extract these teeth. The principle concern is, once again the amount of time the physician oncologist is willing to allow for healing. Impactions requiring extensive bone removal may take longer to heal and are at greater risk for infections, necessitating a possible delay in the start of the radiation treatment. These extractions may be greater problems I the older, physically compromised individual compared with a younger, healthier patient. Since the fully impact tooth does not precipitate many major immediate problems following radiation the decision to extract or not to extract these teeth can only be reached after careful review of all factors. Partially erupted teeth must be considered for extraction particularly if they have been the cause of previous episodes of pericoronal infections. Potential restorative and surgical procedures will be difficult following radiation since resulting trismus will limit access and surgery will result in a risk of compromised wound healing. A limited ability to open makes surgery and restorative and endodontic procedures in posterior quadrants very challenging and has a detrimental effects on the quality of care provided. It is certainly an advantage to extract these partially erupted teeth prior to radiation. Criteria for pre irradiation extraction. Dental disease factors. Radiation delivery factors. Pre irradiation surgery. Post radiation dental disease. Dental maintenance. Criteria for Pre Irradiation Extractions Condition of the residual dentition The goal is to place the dentition in optimal condition so that no high-risk dental procedures need be performed in the post radiation phase. The patients periodontal status is most important in this assessment. An aggressive extraction protocol for dentition with periodontal involvement. Moderate caries are less important as they can be restored and maintained easily.

Dental awareness of patient Patient Motivation It is important that patients posses the motivation and ability to maintain the dentition in sound health. Without the patients health the risk of complications increase immeasurably The less the patients motivation the more aggressive should the extraction protocol be. The patients oral hygiene at the initial examination is often a reliable indicator of future performance. Urgency Of treatment The status and behaviour of the tumor may preclude any pre irradiation extractions Delays secondary to healing can significantly compromise control of the disease. Control of the tumor is the most important consideration. Mode Of Therapy: In external beam radiation there is more exposure to the tissues than implantation technique. While the risk of osteoradionecrosis is more when the implants are close to the bone. Thus all such factor should to be kept in mind before planning any pre extraction surgeries. Radiation field The risk of caries and necrosis is dependent on the radiation field. Where the radiation fbeam includes the major salivary glands and a significant portion of the body of the mandible, as in the base of the tongue, tonsillar pillar, and retromolar trigone carcinomas, radiation-induced xerostomia is sever and the blood supply to the mandile is compromised. This indicates increased incidence of caries and osteoradionecrosis is high in this region. Thus aggressive approach to extraction of teeth is justified. Mandible Versus Maxilla Almost all ORN occurs in the mandible and hardly any in the maxilla. Thus a conservative approach regarding the maxillary teeth is justified.. So a more aggressive approach is mandatory for mandibular teeth especially those that fall in the radiation field. Prognosis Of The Tumor Prognosis is of more importance in-patients for whom palliative and relief measures are indicated. In such patients teeth, which would normally be otherwise extracted, are left in place, as they would otherwise be troublesome and create unnecessary discomfort. Pre Irradiation Surgical Procedures

Radical alveolectomy to be performed, edges of the tissues should be everted and primary closure is obtained. Teeth should be extracted in segments, rather than singly, as it is easier to do alveolectomy and obtain closure. A period of 7-10 days is usually adequate for healing before therapy can commence. Extraction of impacted third molars is not usually indicated unless accompanied with Pain Infection or Abscess Cyst Pericoronitis Dental Maintenance Patient is given oral hygiene instructions and a thorough oral prophylaxis is done. Follow up is done weekly during the therapy and the instructions are reinforced. Post therapy patient is placed on a recall schedule every 3 months for the first year. Fluoride therapy is an integral part of the dental treatment and is initiated immediately. Can vary from fluoride gels to mouth rinses. Has to be continued for a lifetime in some form or the other. Bone Since bone is 1.8 times as dense as soft tissue it absorbs a larger proportion of radiation than does a comparable volume of soft tissue. The mandible absorbs more radiation than the maxilla because of its increased density and this plus the mandibles reduced vascularity compared to the maxilla accounts for the higher incidence of mandibular osteoradionecrosis. The surgeon must smoothly contour the alveolar ridge at the pre radiation dental extractions. If radical alveolectomies are not performed on these patients the resulting alveolar ridge will not readily remodel and will be quite irregular. Construction and wear of mandibular dentures on such an irregular bony base is quite risky in an irradiated patient for it may lead to exposed bone and subsequently to osteoradionecrosis. Periodontium Specific network of the fibers becomes disoriented and the periodontal ligament thickens. Osteoradionecrosis are preceded by periodontal infection associated with teeth in the primary beam of radiation when evaluating teeth for extraction prior to treatment. The periodontal status of the dentition is the most important dental consideration aside from preexisting acute infectious process. Cementum demonstrates changes in its capacity for repair and regeneration is severely compromised. Teeth

There appear to be significant changes in pulp tissue. Pulp shows a decrease in vascular elements with accompanying fibrosis and atrophy. Clinically pulpal response to infection, trauma and various dental procedures appears compromised. Pulpal pain, however, is less severe even in the presence of advanced caries with obvious pulpal exposure. Root sensitivity following full course radiotherapy may be severe in a very small number of patients. Burnishing the exposed surface with a 1% fluoride solution has been effective in reducing pain and sensitivity. If exposure occurs before significant calcification is completed, the tooth bud may be damaged or destroyed. Exposure at a later stage of development may arrest growth and may result in irregularities in enamel and dentin. Preradiation prosthodontic care As noted previously many head and neck oncology patients are elderly and have experienced limited dental treatment. A number wear removable complete or partial dentures, and although in the opinion of the patient the prosthesis are serviceable they may or may not conform to acceptable prosthodontic standards. Regardless of the condition of the dentures, little definitive prosthodontic care is necessary prior to radiation. The severity of resulting mucositis will limit the patients ability to tolerate the prosthesis during therapy, whether or not retention or occlusion is adequate. Since patients may experience a substantial weight loss over the treatment course sufficient change will have occurred in the soft tissues to warrant the fabrication of new dentures once radiation is complete. There is little advantage to relining ill fitting dentures since the procedures can be moderately expensive and will not be a factor in patient comfort during various stages of mucositis. Soft temporary reline materials because of their surface porosity and abrasiveness, make hygiene procedures difficult, serve as a potential reservoir for fungal growth and may be a source of additional mucosal discomfort. Patients are advised that they will in most instances be better served by not wearing dentures during therapy. The patient must be cautioned that continuing to wear the dentures may be the source of significant additional mucosal irritation and lead to delayed healing following the completion of radiation therapy. In most instances the patient will object to being without dentures during therapy for the usual cosmetic and functional reason. The clinician should approach this situation with a sympathetic ear. It is important to the psychological well being of the cancer patient that a degree of normalcy exists in daily life. Such patients have been bombarded with discussions of serious potential problems resulting from radiation and then are asked to suffer the additional indignity of going without dentures. It is important for the patient to feel in control of the decision regarding the use of dentures. More often than not a decision will be made to head the advice of the dentist. Dentate patients with metallic crowns or fixed partial dentures in the treatment field may suffer significant irritation to adjacent soft tissue as a result of backscatter. This problem can be minimized with the use of a custom made, soft plastic stent. The stent should be of sufficient thickness to displace the soft tissue in buccal and lingual directions.

in some cases, the patients fluoride carrier may be used for this purpose. An increasing number of patients with dental implants are being seen at treatment centers. Dental management during radiation therapy Mucositis one of the earliest effects of radiation to the oral cavity is the development of severe soft tissue irritation or mucositis. The soft tissue in the treatment field after a week or two, demonstrates a moderate amount of erythema. As radiation continues, the mucosa may exhibit varying degrees of desquamation and frank ulceration. Resulting pain and dysphagia make it difficult for the patient to eat a well balanced diet, resulting in what may be a significant weight loss. It may be necessary to interrupt therapy if the weight loss becomes critical. The severity of the mucositis is influenced by a number of factors and is not always predictable. Patients with a history of alcohol abuse or smoking for example who continue these habits during radiation suffer the greatest morbidity. Acute mucositis begins during the second or third week of radiation therapy and subsides within 8 to 10 weeks once treatment is completed. A variety of measures have been proposed to help alleviate the patients discomfort, the most significant being good oral hygiene. Frequent daily cleaning of the teeth with a soft brush and mild tasting toothpaste has proven to be beneficial. Frequent oral rinses with a combination of salt and sodium bicarbonate in water or dilute solutions of hydrogen peroxide and water appear to have a soothing effect on the affected areas and aid in keeping the tissue clean and moist. Other therapies have included rinsing with Benadryl elixirs, sucralfate solutions, and topical anesthetics. The mucosa should be cleansed with either the hydrogen or salt solution prior to using Benadryl or sucralfate. This helps remove debris and mucus from the wounds and allows the medication to adhere more intimately to the tissues. Topical anesthetics in dilute form effectively reduce discomfort and can be useful during meals. Since large portions of the oral cavity are anesthetized for a significant period of time, the patient must be cautioned not to inadvertently bite and additionally injure the soft tissues. Loss of taste Loss of taste accompanies radiation to the tongue and palate. This loss occurs rapidly during the first week or two of treatment and in most instances gradually returns to normal once the treatment course is completed. Some questions have been raised regarding the exact cause of the loss of taste. Damage to taste buds and microvilli, disrupted innervations as a result of the radiation and lack of saliva have all been mentioned as possible contributing factors. The condition is primarily an annoyance but adds to the discomfort of the patient during the treatment course. The loss of taste may lead to lack of desire for food and can be an additional cause of weight loss during therapy. It is condition the patient must endure with the understanding that it is rarely permanent. Xerostomia and dental caries

Changes in the quantity and quality of saliva as a result of radiation have been well documented in the dental literature. Beginning with the first course of treatment, salivary flow rates decrease, eventually reaching as low as 1% of normal. Additionally there is a concomitant increase in the numbers of acidogenic and cariogenic microorganisms resulting in a severe, aggressive from of dental caries. Lacking a specific preventive program, the dentist at once time was faced with the unenviable task of continually restoring all tooth surfaces with little hope for success. In an effort to reduce long term complications precipitated by this form of tooth decay patients were frequently advised to have all remaining teeth regardless of their condition extracted prior to radiation. Definitive studies regarding treatment and cause of dental caries in the irradiated patient led to the knowledge that the most effective method of treating this condition was through the daily use of topical applications of fluoride. Both stannous or sodium fluoride have been used in variety of forms with significant success. It has been noted that an additional advantage of stannous fluoride is that it has an antimicrobial effect reducing S mutans counts. Sodium fluoride because of its higher pH is less irritating to compromised soft tissue and is substituted for the stannous form for patients who complain of a burning sensation when using the stannous gel. Gels used with a tray are reported to better cover all tooth surfaces than either fluoride rinses or gels applied with a brush. Patients must be made to understand that they will need to use fluoride once a day, every day for the remainder of their loves. Clinical experience has demonstrated that discontinuing the fluoride applications even for short periods of time, may result in renewed cariogenic activity. Preventive programs based on the topical applications of fluoride coupled with meticulous oral hygiene can all but eliminate the caries problem. There is little reason for any irradiated head and neck cancer patient to experience abnormal dental caries providing he or she is fully complaint monitored regular and appropriately counseled by a dentist. Immediately following the initial prophylaxis and before radiation treatments begin irreversible hydrocolloid impressions are made. Custom trays or carriers which extend to just below the marginal gingiva are fabricated and delivered taking care to relieve any areas that may impinge on soft tissue. The edges of the tray should be made as smooth as possible to avoid soft tissue irritation. This is an important step since the patient will be expected to use the carrier during therapy while experiencing severe mucositis. The patient is instructed to carefully brush his or her teeth. Immediately following brushing the patient is directed to place a sufficient amount of a sodium or stannous fluoride gel into the tray to cover all tooth surfaces. Once positioned the tray and gel must remain in contact with the teeth for a minimum of 5 min. Additionally the patient is asked not to rinse the mouth for approximately 30 min following removal of the tray. As the patient progresses through radiation treatment courses, it is advisable for the dentist to frequently monitor oral hygiene procedures and ensure proper use of the fluoride. Although the preventive treatment described is generally considered the treatment of choice several groups of patients experiencing only partial salivary gland dysfunction may achieve acceptable results by simply brushing with the fluoride gel.

Saliva substitutes and sialogogues The most persistent and certainly the most frustrating morbidity associated with radiation to the head and neck is dry mouth. The condition begins in the first week of therapy and gradually worsens overtime. The patient experiences a need to continually lubricate the mouth and is forced to ingest large quantities of fluid to aid in swallowing at mealtimes. There is a disconcerting change in eating habits with an increased intake of soft moist foods. Food debris accumulates on the oral mucosa and teeth because of the absence of the self cleansing action of saliva making oral hygiene much more difficult. Attempts have been made to stimulate salivary flow rates with sialogogues such as pilocarpine and antholetrithoine. Therapeutic regimens involving administration of these drugs have proven effective for patients with Sjogrens syndrome and for individuals receiving low doses of radiation to limited fields. There is no concrete evidence that the drugs are effective in those individuals receiving high doses of radiation to all major salivary glands. Saliva substitutes have been developed in an effort to alleviate the discomfort and harmful effects of xerostomia. These products consist primarily of carboxymethylcellulose with various salts and flavoring agents added. Results with the use of the substitutes are mixed, related more to the subjective preference of the patient than to any appreciable therapeutic effect. Patients should be offered an opportunity to try the substitute early in the course of radiation treatment. While most individuals discontinue use within a relatively short period, complaining of stickiness or unpleasant taste others find it to be of some benefit. Clinical experience has demonstrated that patients are quite resourceful in developing their own methods of coping with xerostomia. Many carry containers with water or salt and soda solutions with them at all times, rinsing or drinking frequently. Others have been reported to rinse with self developed mixtures of glycerin and fruit juice or mouth rinses with some success. Trismus and fibrosis Trismus may begin shortly after radiation begins. Clinically the patient gradually loses the ability to open the mouth. The condition may be exacerbated by surgery prior to radiation and by radiation fields that include the muscles of mastication or the TMJ. Patients suffering with tumors of the palate, nasopharynx and maxillary sinus are most likely to develop trismus. If unmanaged trismus makes eating difficult and the performance of dental procedures almost impossible. Since primary treatment involves exercising the muscles involved a variety of bite openers or exercise devices have been developed. Each has been proven through clinical use to be substantial value and in most instances effectively increase the oral openings. Positive results are more easily attained with the dentate patient. It must be noted that improvement in the ability to open regardless of the exercise program is not permanent and may regress over a period of even a few hours. The simplest and least expensive method of exercising is with the use of tongue blades. A number of tongue blades are placed along the occlusal surfaces of the posterior teeth. The vertical opening is increased as an additional blade is added slowly and deliberately

to the original stack. The patient is instructed to pause for a few minutes before placing each additional blade. As trismus becomes chronic there is an appreciable amount of discomfort involved in performing the exercises, regardless of the method used, resulting in patient noncompliance. Chronic trismus gradually becomes fibrosis of the elevator muscles and at this late stage is not amenable to stretching as a solution. Exercise must begin early in treatment and results are predicted on the patients willingness to cope with the exercise regimen. Use Of Prosthodontic Stents & Splints Positioning stents Shields Recontouring devices Positioning of direct source Templates Tissue bolus devices. Shielding and positioning stents In an effort to minimize morbidity associated with radiation to the oral cavity, soft tissues not directly involved with tumor can be displaced or shielded. The radiation oncologist frequently uses a tongue blade taped to a cork for example, when treating lesions involving the tongue. This simply in effect lowers the mandible and tongue preventing radiation to the nonaffected parotid gland and maxilla to some degree. Over time dental oncologists in cooperation with radiation therapists have developed more sophisticated shielding and positioning devices that have proven to be useful in limiting radiation effects. The fabrication of one of these stents or splints is time sensitive since it must used in the planning of treatment fields. The physician will usually desire treatment to begin as quickly as possible and may have concerns regarding the time involved in fabricating a customized stent or splint. Some radiation oncologists find the fabrication of complex customized stent or splint. Some radiation oncologists find the fabrication of the complex, customized stents unnecessary. This opinion appears to be based more on the availability of an oncology oriented dentist rather than unsuccessful clinical results. Generally fabrication is a relatively uncomplicated procedure and can be completed expeditiously using basic prosthodontic clinical and laboratory techniques. Positioning stents One of the frequently used positioning stents serves to lower the tongue and places it in a repeatable position during therapy. Since the stent also serves to separate the mandible and maxilla in an open position, maxillary structures such as the palate upper gingiva and buccal mucosa are spared radiation effects. Maxillary and mandibular impressions are made with irreversible hydrocolloid. In the case of the completely edentulous patient, the impressions must be properly extended to ensure stability of the finalized bases. An interocclusal record is obtained at the widest opening necessary to ensure that maxillary structures are not included in the

treatment field. Casts are recovered and mounted on a simple articulator. Baseplate wax is softened and placed over the incisal and occlusal surfaces of all teeth. Two sheets of baseplate wax are then attached to the right and left sides of the mandibular segment. This flat sheet extends posteriorly as far as tolerable, covering the entire tongue and maintaining it in the appropriate treatment position. An opening in the anterior portion of the stent between the pillars acts as a shelf upon which then tip of the tongue rests and serves to help maintain a repeatable tongue position. The waxed stent is evaluated in the mouth, and the radiation therapists verify tongue position. Additionally an assessment is made regarding the patients ab ility to tolerate the stent position it correctly and remove it easily. The waxed stent is flasked and processed in clear heat cured or autopolymerizing resin. A length of stainless steel wire is embedded in the horizontal lingual extension. The wire defines the position of the dorsum of the tongue on stimulation films and is of value when planning radiation fields. The stent is highly polished and checked carefully for any scratches or sharp edges that may cause irritation during therapy. The radiation therapists confirm the final treatment fields with the completed stent in place. Shielding stents It is possible when treating tumors of the buccal mucosa, skin or alveolar ridge with electron beam therapy to protect uninvolved adjacent structures by means of a shielding stent. It is known that a 1 cm thickness of a Lipowitz alloy consisting of silver, copper, tin, antimony and lead will effectively reduce an 18MeV electron beam by approximately 95%. The metal is only effective, however when electrons are used. Generally an acrylic resin stent is made. A portion of the stent is removed and the metal is heated, poured into the prepared recess, and allowed to cool. The metal is then covered with a layer of acrylic resin to prevent backscatter to adjacent tissue. Maxillary and mandibular impressions are made using a combination of modeling plastic and irreversible hydrocolloid in an effort to displace the tongue laterally. An interocclusal wax record is made in centric relation at a slightly opened vertical dimension. The impressions are poured and the recovered casts are mounted on a simple articulator in the open position. Baseplate wax is placed over the mandibular teeth on the side to be treated and side to be treated and the articulator is closed to form an index of both maxillary and mandibular teeth. A wax bolus is formed and attached to the occlusal index. The bolus should extend approximately 1 to 2cm lingually and contact both the palate and the floor of the mouth. The lingual surface of these stent is made as flat as possible. The waxed stent should be tried in the mouth to confirm appropriate extension posteriorly and sufficient displacement of the tongue. Once the shape has been confirmed, the waxed stent is flasked and processed in clear, heat cured or autopolymerizing acrylic resin. The stent is recovered and polished as carefully as possible making certain that no sharp edges or rough surfaces exist. A recess extending within 8 to 10mm of the entire circumference of the stent is cut into the resin to an appropriate uniform depth dependent on the megavoltage of the electrons to be used. The Cerrobend is heated and the molten metal poured in the hollowed portion of the stent. The metal melts at

1580F, at which temperature the acrylic resin will not be damaged. After cooling the patients name can be cut into the metal surface with a round bur for identification purposes. The exposed metal is covered with additional acrylic resin to prevent the metal from contacting mucosal surfaces and to minimize backscatter. The completed stent is tried in the mouth in consultation with the radiation therapists. Minor final modifications can be made at this time. It may also be necessary to adjust the stent as treatment progresses to avoid irritation of radiated soft tissues and to accommodate the limiting effects of trismus. In some situations both photons and electrons are used in treatment. Since the tissues must be in the same position when either modality is used, a duplicate stent without the metal is employed during the photon phase of treatment. Modifications can be made in the basic design of the positioning and shielding stents to accommodate the needs of the most treatment situations. It may be advantageous to make the stent in several pieces. This facilitates insertion and removal as treatment progresses and trismus becomes a problem. A number of other stents have been described that function as carriers for radioactive sources and positioning cones. The basic procedures for developing these devises are essentially the same as those discussed above. There are only a few fundamental rules governing fabrication of these stents and in many instances design is based on the ingenuity of the dentist involved and a cooperative relationship between dentist and radiation therapists. Recontouring Devices To Simplify Dosimetry Usually useful in treating skin lesions associated with upper and lower lip. Due to the curvature of the lip the doses will be delivered less to the corners of the mouth. This stent aims to flatten the lip and the corners of the mouth thus placing the entire lip in the same plane. Positioning Of A Direct Source Used in Brachy therapy. A previously fabricated stent or radiation carrier is used to position the radioactive source. Radiopaque shields or tissue positioners can be incorporated to avoid unnecessary radiation to the surrounding tissues. Templates This aids in direct positioning of the radiation sources and to gauge its depth of insertion. Any pre existing prosthesis (CD) can also be used as templates for positioning of these implants. Tissue Bolus Devices Irregular tissue contours create uneven dose distributions. As a result some areas within the field get more doses and than others. A bolus is a tissue equivalent material placed into irregular tissue contours to produce a more homogeneous dose distribution. Commonly used materials are saline, wax and acrylic resin. Dental Management Following Radiation Soft Tissue Necrosis

Is defined as a non neoplastic mucosal ulceration ring in the postradiation field and which does not expose bone. These lesions occur most often following treatment with interstitial implants and peroral cone modalities. These necroses occur within 1 year after completion of radiation therapy. A tumor recurrence usually presents with irregular, indurated margins, whereas soft tissue necroses present with regular, non-indurated margins. Soft tissue necroses are mostly precipitated by tongue and cheek biting which often warrants occlusal adjustment in dentulous patient, or removal of mandibular denture in the edentulous patient. Treatment consists of establishing the diagnosis and close follow-up. In severe cases, healing can be accelerated by hyperbaric oxygen. Mucositis and Loss of Taste Once radiation treatment is complete, acute mucositis will subside gradually over a period of 6 to 8 weeks. Since the affected soft tissue will remain constantly irritated to some degree, the patient is advised to continue using rinses. The length of the time necessary for recovery is dependent on the severity of damage to the soft tissues and in some instances may take months. Generally taste acuity will return to the levels that the patient perceives as normal. Xerostomia and Dental Caries The loss of salivary function is permanent, and salivary flow rates have been proven to decrease with time. Oral tissues will remain dry and uncomfortable, forcing the patient to rinse frequently with no hope for a positive therapeutic solution to the problem. A program that includes meticulous oral hygiene, frequent daily rinsing and use of saliva substitutes offers some hope for temporary relief. Since dental caries is directly related to the effects of the decrease in saliva, it is essential that the program of oral hygiene and the daily topical application of fluoride be maintained. Candidiasis Causes Xerostomic conditions and change in normal flora Symptoms Abnormally sore or burning mouth Generalized inflammation involving the palate and cheeks, but lacking the whitish patches generally associated with Candida Treatment Troches or rinses containing chlotrimazole or nystatin are prescribed. Bacterial infection may be treated with appropriate antibiotics. Treatment is continuous for a period of 2 weeks. It has been suggested that meticulous oral hygiene and frequent rinsing with salt and soda or dilute solutions of hydrogen peroxide may have a preventive effect.

Clinical experience has demonstrated that Candida may be harbored in or on the surface of dentures or obturators and play a role in chronic reinfection. Soaking prostheses in an anti fungal solution or dilute hypochlorite for complete dentures has proven to be an effective preventative measure. Trismus and Fibrosis Trismus and fibrosis will continue to be problems following radiation. In most instances these conditions will increase in severity with time, leading to oral openings of 10 to 15 mm. Patients will have difficulty in placing dentures or obturators, with resultant compromise in nutrition. The condition is only improved with constant exercise. The more frequent and diligent the exercise regimen, the more beneficial is the result. It is recommended that the patient perform exercises several times each day. Dental Extractions There is a great deal of controversy regarding dental surgery following radiation. Some clinicians have reported few incidents of ORN after removal of teeth following radiation therapy. Localized periapical and periodontal infections can be managed conservatively with antibiotics, avoiding the immediate need for tooth removal. In situations involving single tooth, endodontics should be considered an option, even when the tooth is considered non restorable. Following endodontic therapy, the badly decayed tooth crown is amputated to prevent irritation to the tongue or cheek and the exposed portion of the root canal is sealed with a permanent restoration. A tooth managed in this manner may serve no function but, more important, extraction is avoided. With the use of hyperbaric oxygen, extensive oral surgery can be performed with a substantially diminished risk of necrosis. Hyperbaric protocols involve a series of up to 20 dives before and after surgery in a small, sealed hyperbaric chamber. Each daily dive is 90 minutes long. The patient must be judged physiologically and psychologically capable of enduring these conditions. A thorough medical evaluation is a prerequisite for treatment. Teeth are extracted following the initial 20 dives, extractions are generally performed in the operating room. Necessary surgery including extractions, alveolectomies, and tori removal is completed using atraumatic technique. The wounds are closed primarily. Following the surgical procedures, the patient returns for the completion of the second phase of hyperbaric protocol. Additional dives may be necessary if the wound healing is not complete. Clinical evidence indicates that using this procedure greatly reduces the risk of ORN and serves as an important tool in the management of the irradiated patient. Osteoradionecrosis Osteoradionecrosis is defined by Marx as the presence of exposed bone in the region of radiation therapy for 6 months with or without pain. Predisposing factors

Diseased teeth Use of partial or complete dentures Periodontal deficiencies associated with dentitions retained within the treatment field. Treatment options

Osteoradionecrosis associated with external beam Local irrigation and packing of iodoform gauze impregnated with tincture of benzoin, when the dose to bone in the local area is less than 6500 cGy and the exposure is localized. When the dose to the bone is above 6500 cGy, hyperbaric oxygen combined with a surgical sequestrectomy should be considered. Sharp bony projections should be smoothed with an airotor. Antibiotics are necessary only to control local acute infectious episodes involving the adjacent soft tissues. Osteoradionecrosis associated with external beam and Interstitial implants If the external beam dose to the bone is below 5500 cGy the prospects for conservative therapy are excellent and surgical sequestration in combination with hyperbaric oxygen is rarely needed. Hyperbaric Oxygen Therapy A major advancement in the treatment of osteoradionecrosis has been the use of hyperbaric oxygen. Hyperbaric oxygen therapy (HBOT) is a medical treatment that uses the administration of 100 percent oxygen at a controlled pressure (greater than sea level) for a prescribed amount of time-usually 60 to 90 minutes. It helps the body heal itself by making oxygen available to body tissues, or organs, which are not receiving an adequate supply because of illness or trauma. The air we normally breathe contains about 21% oxygen, which is carried throughout our bodies by red blood cells in blood. During HBOT, the 100% oxygen we breathe, combined with higher pressure, delivers up to 15 times the oxygen content to all body fluids, including plasma, cerebrospinal fluid surrounding the brain and spinal cord, lymph, and intracellular fluids. This allows oxygen levels to increase even in areas with blocked or compromised blood supply as a result of injury or illness,as well as in areas of tissue damage. Increasing tissue oxygen levels produces several important long term therapeutic benefits including enhanced growth of new blood vessels; increased ability of white blood cells to destroy bacteria and remove toxins; increased growth of fibroblasts (cells involved in wound healing); and enhanced metabolic activity of previously marginally functioning cells including brain neurons. Hyperbaric oxygen stimulates neovascular proliferation in marginally necrotic tissues, enhances fibroblastic proliferation, enhances the bactericidal activity of white blood cells and increases the production of bone matrix. The Marx protocol for the treatment of osteoradionecrosis

Stage I: These patients have osteoradionecrosis but without pathologic fracture, orocutaneous fistula, or radiographic evidence of bone resorption to the inferior border of the mandible. Marx recommends that patients in this group be given 30 hyperbaric treatments (2.4 atmospheres, 100% oxygen for 90 min). If at the end of the 30 treatments, there is clinical evidence of improvements, another 20 treatments are added. If no clinical improvement is noted the patient is considered as nonresponder and advanced to stage II. Stage II: After 30 hyperbaric treatments, non-responders are taken to surgery. A surgical sequestrectomy in the local area is performed, and the wound is closed primarily in 3 layers over a base of bleeding bone. An additional 10 hyperbaric treatments are given; if the wound dehisces the patient is identified as a nonresponder and advanced to stage III Stage III: Non-responders from stage II therapy and patients presenting with orocutaneous fistula, pathologic fracture or radiographic evidence of bone resorption to the inferior border of the mandible, are considered stage III patients. Following the initial 30 hyperbaric treatments, bony segments of non vital mandibular bone are resected transorally with the aid of tetracycline fluorescence under ultra violet light. External fixation of the mandibular segments is achieved, orocutaneous fistulae are closed, and soft tissue deficits restored with local or distant flaps. Another 10 hyperbaric treatments are given and the patient is advanced to stage IIIR. Stage III R: 10 weeks after resection, the mandible is reconstructed with a bone graft using a transcutaneous exposure. Oral contamination of the surgical wound is to be avoided. Mandibular fixation is achieved and maintained for 8 weeks. Ten hyperbaric treatments are given post operatively. Contraindications to hyperbaric treatment include persistent tumour, optic neuritis, active viral disease states and untreated pneumothorax. Complications include barotrauma of the ear, temporary myopia, and in rare instances, pulmonary fibrosis. The pre-hyperbaric oxygen work up includes a history and physical examination, chest film, ophthalmologic exam, hearing test, and a complete blood count. Management of osteoradionecrosis with myocutaneous flaps or free flaps The irradiated nonvital bone is removed surgically down to viable bone. Administration of tetracycline prior to surgery, and use of an ultraviolet light source during surgery, aids in identification of bone that retains its viability. The exposed bone is then covered with a myocutaneous flap. These flaps bring their blood supply along with them and thus facilitate healing. Post Radiation Prosthodontic Care Divided into dentulous and edentulous patients Dentulous patients Fluoride application Follow-up and restorative care Endodontic therapy as an alternative

Edentulous patients a. Soft liners: The silicones exhibit reduced wettability and this phenomenon contributes to an increased drag that does not allow the denture to slide easily over the dry mucosal surface during function. The high risk of tissue abrasion plus the poor adjustability of silicone have influenced clinicians to abandon its use in irradiated patients. There is significant increase in fungal population in patients with radiation-induced xerostomia resulting in rapid deterioration of silicone liners. Since trauma caused by dentures may increase the potential risk of mucosal irritation and subsequent bone exposure, some have suggested waiting at least 6 months to a year before dentures are contemplated. Upon initial oral examination important clinical manifestations of the radiation treatment include appearance of oral mucous membranes, scarring and fibrosis at the tumour site, degree of trismus, presence and nature of lymphoedema and status of salivary function. Translucent boggy mucosa with prominent telengiectasia implies poor tolerance to prosthodontic restorations. With an increased risk of compromising mucosal integrity where severe mucosal changes are present, use of dentures may be delayed or forbidden. Scar tissue is mostly unyielding and the slightest over extension may result in a mucosal perforation. The less saliva, the more difficulty the patient will have in tolerating the dentures. In addition the retention of the maxillary complete denture may be compromised due to the film thickness of scanty and more mucinous saliva. Mandibular ridges with severe bilateral undercuts or excessive ridge resorption with little attached mucosa are poor candidates for complete denture service following radiation therapy. b. Impression If xerostomia is particularly profound, a thin coating of petrolatum may be applied over the soft modeling plastic to prevent its sticking to the dry mucosa. Particular attention should be paid to the lingual extension of the mandibular denture because over extension could result in a mucosal perforation. Displacement of the tissues of the floor of the mouth, in an attempt to obtain peripheral seal, is not advocated. Peripheral seal is virtually impossible to obtain in these patients because of the curtailment of the patients salivary flow. Efforts to develop the lingual flange should be directed towards gaining stability and support rather than retention. Edema of the tongue and floor of the mouth, which is particularly prominent if the patient has undergone a radical neck dissection, will occasionally be sufficiently large to compromise floor of mouth posture and limit the extent of the lingual flange. Cutting away the denture base in regions in the field of irradiation has been advocated in some patients. c. Vertical dimension The clinician should consider reducing the vertical dimension of occlusion. This consideration is based on 2 lines of reasoning. First reducing the vertical dimension may limit the extent of forces applied to the supporting mucosa and bone during a forceful closure. Second in patients with clinically significant trismus, entrance of the bolus is more easily accomplished by increasing the interocclusal space.

d. Occlusal forms The authors have come to favor lingualised or monoplane occlusal schemes with balance facilitated by posteriorly situated balancing ramps. A well balanced non interfering occlusion is an absolute necessity regardless of the tooth form used e. Delivery and post insertion care An appointment to evaluate the waxed denture allows verification of interocclusal records and provides the patient an opportunity to satisfy esthetic considerations. The prosthesis is flasked and processed using heat cured polymethyl methacrylate. Soft materials have been suggested for use as denture bases. In the past, these materials have offered little advantage over hard base materials because of their coarse surface and propensity for support of fungal growth. Delivery procedures must be meticulously performed. Indicating paste is used to identify areas of excessive pressure. Denture borders should be carefully evaluated for areas of overextension, paying special attention to the retromylohyoid area. Remounting the dentures provides an opportunity for verifying the accuracy of interocclusal records and developing a noninterfering occlusion. Upon completion of these procedures, the dentures are highly polished. Some clinicians advocate that the tissue bearing surface of the denture also be polished to eliminate any surface roughness in an effort to minimize tissue irritation. The patient should be advised regarding the effect xerostomia and compromised mucosa have on the potential for prosthodontic success and should be cautioned to remove the dentures if any soreness or irritation develop and to see the dentist as quickly as possible. The benefits of removing the dentures while asleep and maintaining appropriate oral hygiene procedures must be explained. Additionally the patient must be seen at frequent intervals during the first few weeks following delivery of the dentures. Two appointments a week provide ample opportunity to intercept any problems that may develop. Implants in irradiated tissues Irradiation of head and neck tumour predispose to changes in bone, skin and mucosa, which affect the predictability of osseointegrated implants. Long term function of osseointegrated implants is dependent on the presence of viable bone that is capable of remodeling and turn over as the implant is subjected to stresses associated with supporting, retaining and stabilizing prosthetic restorations. The viability of irradiated bone may not be sufficient for remodeling and turn over of bone. Predictability of implants in irradiated bone Long term function of osseointegrated implants is dependent on the presence of viable bone that is capable of remodeling and turnover as the implant is subjected to the stresses. There is increased risk of ORN . The success -failure rate is dependant on 1. Anatomical site. 2. Dose to the site. 3. Use of hyperbaric oxygen.

Implants already in place tend to add to the Backscatter thus the tissues around tend to get as much as 15% more than other areas. Osseointegration is impaired in bone that has received more than 5000 cGy of treatment. There is always a risk of failure and osteoradionecrosis when placing implants in irradiated bone. Hyperbaric oxygen can help in its success. Abutments and all super structures are to be removed prior to the therapy. Mucosa should be closed over the implant fixtures. They should only be used once therapy is over, then the prosthesis can be reseated Side effects and complication of various doses of radiotherapy: Under 3,000 cGy - mucositis, candidiasis, xerostomia & dysgeusia begin Over 3,000 cGy xerostomia (permanent) and taste dysgeusia , altered saliva (thick, more acid, changed flora) Over 5,000 cGy trismus concerns for osteoradionecrosis Over 6,000-6,500 cGy significant concerns for osteoradionecrosis Stimulated Whole Salivary Flow Rates - week after beginning RT 57% decrease & after 5 weeks (end of treatment) 76% decrease; years after RT 95% decrease. Endocrine abnormalities: Hypothyroidism, Parathyroid adenoma and hyperthyroidism. Atherosclerosis occurs in doses more than 50 Gy Progressive muscle fibrosis may limit the neck and shoulder function. Some times trismus may also seen. Visual impairment may occur due to radiation keratitis, cataract and optic neuritis. Radiation neuritis. Secondary infection. Development of maxillofacial deformity and tooth development in children. Conclusion Radiotherapy is a boon to the cancer patients, by radiation therapy the affected part is preserved from complete excition; but it do cause some adverse changes in normal cell which are making them vulnerable to infections further results in tissue necrosis. These adverse effects can be reduced by proper treatment planning and patient education. Radiation Therapy will improve the patients quality of life if it is used properly, we could say it as a properly planned radiotherapy will give the new life to the cancer patients. As being a prosthodontist we need to know these adverse effect as well as the construction of the protecting shields and maxillofacial prosthesis. References: 1.Taylor T T, Clinical Maxillofacial Prosthetics, Quintessence publications, 1 st edition, Illionis, 2000, pp 37 52

2.Beumer J I, Curtis T A, Marunick M T, Maxillofacial rehabilitation Prosthodontic and surgical considerations, Tokyo, 1995, 43 105 3. doktor.baromedical.hu/media/wysiwyg/PDF/Osteoradionecrosis.pdf