RADIOTHERAPY ON HEAD AND NECK

Radiotherapy has the ability to destroy neoplastic cells

while sparing normal cells. However in practice, normal
tissues experience some undesirable effect.

Radiation affected hematopoietic cells, epithelial cells,

and endothelial cells soon after radiotherapy begins

Salivary glands and bone are relatively radioresistant, but

intense vascular compromise may result in salivary glands
and bone damage

RADIATION EFFECTS ON
ORAL MUCOSA

Initial effect on oral mucosa (first 1 or 2 weeks) :

erythema that may progress into severe mucositis

with or without ulceration

Pain

Dysphagia that may lead to inadequate nutritional

intake

Loss of taste

Long term effect: Submucosal fibrosis, which

make mucosal lining less pliable and less resilient.
So, minor trauma may create ulcerations and
take weeks or months to heal

RADIATION EFFECTS ON
MANDIBULAR MOBILITY

Radiation may lead :

Pterygomasseteric sling and periauricular

connective tissues become inflamed

Muscles become fibrotic and tends to contract

Articular surfaces degenerate

Usually occuring over the first year after radiation

therapy and painless

TRISMUS

RADIATION EFFECTS ON
SALIVARY GLANDS

Salivary glands damage will result to atrophy, fibrosis, and degeneration

Xerostomia

Xerostomia leads to:

Difficulty with tasting, chewing, and swallowing

Sleeping difficulty

Esophageal dysfunction (including chronic esophagitis)

Nutritional compromises

Higher frequency of intolerance to medications

Increased incidence of glossitis, candidiasis, angular cheilitis, halitosis, and

bacterial sialadenitis

Decreased resistance to loss of tooth structure from atrition, abrasion and erosion

Loss of buffering capacity

Increase susceptibility to mucosal injury

Inability to wear dental prostheses

Rampant (radiation) caries decay around the entire circumference of the

cervical portion

Increase in oral infections such as candidiasis

TREATMENT OF XEROSTOMIA

Replacement / Stimulation of saliva:

REPLACEMENT

Water

Glycerin (contains several ions in saliva, mimic the

lubricating action of saliva)

Carboxymethylcellulose (mucin-based products

which animal-derived)

STIMULATION

Sugar-free chewing gum

FDA approved:

Pilocarpine hydrochloride (4 x 5mg / day)

Cevimeline hydrochloride (3 x 30mg / day)

RADIATION EFFECTS ON
BONE

Osteoradionecrosis is devitalization of the bone by

cancericidal doses of radiation

The bone virtually nonvital from an endarteritis

because of elimination of the fine vasculature
within the bone.

Continual process of remodeling does not occur

(e.g sharp areas will not smooth themselves)

Mandible is denser and poorer blood supply, so

mandible is the most commonly affected with
nonhealing ulcerations and osteoradionecrosis

Other effects of Radiation

Alteration normal oral flora

Overgrowth of anaerobic species and fungi

This may because of radiation and or xerostomia

Candida albicans commonly thrives, frequently

needed nystatin or 0,1% chlorhexidine (Peridex)
which has antibacterial and antifungal effects

EVALUATION OF DENTITION
BEFORE RADIOTHERAPY

SHOULD TEETH BE EXTRACTED? Consideration:

Condition of Residual Dentition

Patients Dental Awareness

Excellent OH Retain as many teeth as possible

Neglected OH Will be more difficult

Immediacy of Radiotherapy

Immediate RT: maintain the dentition

Delayed RT: may give time for dental management, need to work
closely with the patient

Radiation Location

Poor prognosis teeth should be extracted before RT

The more salivary glands and bone involved, the more severe
xerostomia and vascular compromise

Radiation dose

Higher radiation dose more severe normal tissue damage

PREPARATION OF DENTITION FOR

RADIOTHERAPY AND
MAINTENANCE AFTER IRRADIATION

Prophylaxis like topical fluoride application using fabrication

of custom trays

Stop smoking and alcohol consumption

During radiation treatment, should rinse the mouth at least

10x / day with saline

Chlorhexidine mouth rinse 2x / day

The Dentist should control 1x / week

Application of nystatin or clotrimazole (overgrowth Candida

albicans)

Monitor ability of mouth opening physiotherapy exercises

Weighed weekly to determine adequate nutritional status

May be necessary to feed via nasogastric tube

METHOD OF PERFORMING
PREIRRADIATION EXTRACTIONS

Concepts of bone preservation are disregarded

Remove a good portion of the alveolar process

along with the teeth (using burs or files to smooth
the bony edges) and achieve a primary soft tissue
closure

Prophylactic antibiotics are indicated

The Dentist is in a race against time. If the wound

fails to heal, the radiotherapy will be delayed. If
the radiation is delivered before the wound heals,
healing will take months or even years

INTERVAL BETWEEN PREIRRADIATION

EXTRACTIONS AND BEGINNING OF
RADIOTHERAPY?

No categoric answer

Traditionally: 7-14 days between tooth extraction

and radiotherapy

If possible: 3 weeks after extractions

If wound dehiscence has occured, the

radiotherapy should be delayed if possible

Daily local wound care with irrigations and post

op Antibiotics until soft tissues have healed

IMPACTED THIRD MOLAR

REMOVAL BEFORE RADIOTHERAPY

Partially erupted: removal may be prudent, to

prevent pericoronal infections

Totally impacted: Keep it remain in place is more

expeditious

METHODS OF MANAGING CARIOUS

TEETH AFTER RADIOTHERAPY

Must be immediately cared

Full crowns are not warranted because recurrent

caries is more difficult to detect

Flouride application

Endodontic intervention with systemic antibiotics

TOOTH EXTRACTION AFTER

RADIOTHERAPY

Post irradiation extractions is most undesirable, because

the outcome is uncertain

If the tooth is needed to be extracted, perform routine

extraction without primary closure or surgical extraction
with alveoloplasty and primary closure, both has similar
results: a certain concomitant incidence of
osteoradionecrosis

Use of antibiotics is recommended

Use of hyperbaric oxygen (HBO) before and after tooth

extraction

HBO dives 20-30 before extraction and 10 more after

extractions

Usually 1x / day. So, it takes 4-6 weeks to get the 20-30

treatments and 2 weeks of treatment after surgery

Marx et al: Incidence of Osteoradionecrosis of group with use

of AB only : AB+HBO = 5,4% : 30%

DENTURE WEAR IN POSTIRRADIATION

EDENTULOUS PATIENTS

With denture, patient has the risk of causing

ulceration of the mucosa

Soft denture liner may be a solution

Denture fabrication is made once the acute

effects of irradiation have subsided

Denturers fabrication must be certain that

denture base and occlusal table are designed so
that forces aare distributed evenly throughout the
alveolar ridge and that lateral force on the
denture are eliminated

USE OF DENTAL IMPLANTS

IN IRRADIATED PATIENTS

The more radiation delivered, the higher the failure rate for
endosseous implants

The longer the duration betweenn radiation treatment and

implantation, the higher the failure rate

When implants in irradiated patiens fail, they usually fail

early, before prosthetic reconstruction indicating a failure
of osteointegration

The combination of radiation and chemotherapy has a

particularly negative effect on the outome for
osseointegration

Implant survival in irradiated patients tends to he higher in

the maxilla than in the mandibule

Shorter implants have the worst prognosis

HBO treatment reduces implant failure rates

MANAGEMENT OF PATIENTS WHO

HAVE OSTEORADIONECRIOSIS

Patient should discontinue wearing any prosthesis

Decreased vascularity of the tissues and do not

gain ready access to the area to perform the
function of Antibiotics

Nonhealing wounds or extensive areas of

osteoradionecrosis is needed surgical
intervention.

HBO can improve results greatly in conjunction

with surgical intervention

DENTAL MANAGEMENT OF
PATIENTS RECEIVING SYSTEMIC
CHEMOTHERAPY FOR MALIGNANT
DISEASE

Antitumor effect of cancer chemotherapeutic

agents is based on their ability to destroy or retard
the division of rapidly proliferating cells

Normal host cells that have a high mitotic index

are affected. Most affected are the epithelium of
the gastrointestinal tract and the cels of the bone
marrow

EFFECTS ON ORAL
MUCOSA

Reduce the normal turnover rate of oral

epithelium atropic thinning, which manifested
clinically as painful, erythematous, and ulcerative
mucosal surfaces in the mouth.

Changes are seen within 1 week of the onset of

antitumor agents

Effects are usually self limiting, spontaneous

healing within 2-3 weeks after cessation of the
agent

EFFECTS ON
HEMATOPOIETIC SYSTEM

Myelosuppression : Leukopenia, Neutropenia,

Thrombocytopenia and Anemia

Within 2 weeks the white blood cell count falls to

an extremely low level

The oral effect: Marginal gingivitis, and bleeding

from the gingiva is common

Overgrowths of oral flora, especially fungi

Thrombocytopenia can be significant, and

spontaneous bleeding may occur

Recovery from myelosuppresion is usually

complete 3 weeks after cessation of
chemotherapy

EFFECTS ON ORAL
MICROBIOLOGY

Chemotherapeutic agents Immunosuppressive

side effect overgrowth of microbes,
superinfection with gram (-) bacili, and
opportunistic infections

Most patients with chemotherapy are treated

with sytemic antimicrobial agents

Frequent overgrowth organism: Candida species

GENERAL DENTAL
MANAGEMENT

Chemotherapy has minimal effects on the vasculature, so

dental management is easier
Primary concerns: bone marrow suppression
Patient being treated for hematologic neoplasm (e.g
leukemia) both the disease and chemotherapy lead to
decrease in functional blood elements risk of infection &
hemorrhage
In non hematologic neoplasm, risk of infection &
hemorrhage only during the course of chemotherapy
Prechemotherapy dental measures:

Prophylaxis

Fluoride treatment

Necessary scaling

Removal of unrestorable teeth

GENERAL DENTAL
MANAGEMENT

Dental procedures requirement:

WBC 2000/mm3

At least 20% PMN

Platelet 50.000/mm3

Prophylactic Antibiotics should be given if

chemotherapy within 3 weeks of dental treatment

Removable dental appliance should be left out (to

prevent ulceration of fragile mucosa)

TREATMENT OF ORAL
CANDIDIASIS

Topical application of antifungal

Or oral rinses, oral tablets, and creams

Oral rinses are less efficacy

tablet are most accepted forms

creams are helpful for oral commissures or

prosthetic device surfaces

Most common topical medications: Clotrimazole

and Nystatin. 4x daily for 2 weeks

Clotrimaazole troches 4 x 5 times a day

Stronger drugs: Ketoconazole or Fluconazole

Other : Chlorhexidine mouth rinse

DENTAL MANAGEMENT OF PATIENTS

WITH BIPHOSPHONATE-ASSOCIATED
OSTEONECROSIS OF THE JAW (BOJ)

BOJ is a condition of chronically exposed necrotic

bone (painful and often infected)

Bone exposure might occur spontaneously or

more commonly following an invasive dental
procedure

Complains: halitosis, difficulty eating & speaking,

extreme pain

The lesions are persistent and do not respond to

debridement, antibiotic, or HBO therapy

BIPHOSPHONATES

Biphosphonates are used to treat osteoporosis, malignant

bone metastasis, Pagets disease of bone, and
hypercalcemia of malignancy

Biphosphonates also have antiangiogenic properties

tumoricidal

Biphosphonates bind to bone and incorporate in osseous

matrix. During bone remodelling the drug is taken up by
osteoclasts and internalized in the cell cytoplasm inhibit
osteoclastic function and induces apoptotic cell death

The result: bone becomes suppressed and shows little

physiologic remodelling becomes brittle and unable to
reapir physiologic microfractures

CLINICAL SIGNS AND

SYMPTOMS OF BOJ

Exclusively affects the jaws

Clinical: ulcer with exposed bone in a patient who

has had a dental extraction

May be asymptomatic

May have severe pain (if necrotic bone

becoming infected and exposed)

Osteonecrosis often progressive and lead to

extensive areas of bony exposure and
dehiscence

DENTAL CARE FOR PATIENTS START

TAKING BIPHOSPHONATES

Minimize the risk of occurence of BOJ

Provide dental care early in the treatment

Teeth with poor prognosis should be removed

before or as early as possible after administration
of biphosphonates

Should be delayed for 4-6 weeks after invasive

procedures (e.g tooth extraction)

Elimination of all potential sites of infections

Restorative dentistry

Evaluation on prosthodontic appliances (fit,

stability, and occlusion)

DENTAL CARE FOR

PATIENTS WITH BOJ

Treatment directed for elimminating or controlling pain and preventing

progression of exposed bone

Eliminating sharp edges using bur

Attempts to cover exposed bone with flaps may cause more bone
exposure and worsening of symptoms with risk of pathologic fracture

NONE are successful : Major surgical sequestrectomies, marginal and

segmental mandibular resections, partial and complete maxillectomies
and HBO therapy

Use of Chlorhexidine 3-4x/day

If the tooth is unrestorable because of caries root canal treatment

and amputation of the crown may be a better option than removing
the tooth unless it is very loose

Relining a denture with soft liner to promote a better fit and to minimize
soft tissue trauma

Odontogenic infections treated aggressively with systemic antibiotics

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