Box 26-7

Guidelines for Tooth Extraction in Patients Scheduled to Receive Head and

Neck Irradiation (Including the Mouth) or Chemotherapy
Indicators of Extraction

Pocket depths 6 mm or greater, excessive mobility, purulence on probing

Presence of periapical inflammation

Broken-down, nonrestorable, nonfunctional, or partially erupted tooth in a patient

who is noncompliant with oral hygiene measures

Patient lack of interest in saving tooth/teeth

Inflammatory (e.g., pericoronitis), infectious, or malignant osseous disease

associated with questionable tooth
Extraction Guidelines

Extraction should be performed with minimal trauma, with timing as follows:

At least 2 weeks,* ideally 3 weeks, before initiation of radiation therapy

At least 5 days (in maxilla) before initiation of chemotherapy

At least 7 days (in mandible) before initiation of chemotherapy

Trim bone at wound margins to eliminate sharp edges.

Obtain primary closure.

Avoid intraalveolar hemostatic packing agents, which can serve as a nidus for
microbial growth.

Transfuse if the platelet count is less than 50,000/mm3.

Delay extraction if the white blood count is less than 2000/m or the absolute
neutrophil count is less than 1000/m or expected to be this level within 10 days;
alternatively, prophylactic antibiotics (cephalosporin) can be used with extractions that are
mandatory.
*
In select circumstances in which healing will not be compromised, a minimum of 10
days is acceptable. Biologic modifiers that promote healing (e.g., vitamin C) may be useful in
these circumstances. Alternatively, if these time recommendations cannot be met before
initiation of chemotherapy, a root canal procedure can be performed to reduce the number
of viable microbes; then the extraction can be performed after the white blood cell count
returns to sufficient levels.
Box 26-11
Recommendations for Invasive Oral Procedures in the Cancer Patient
Undergoing Chemotherapy in an Outpatient Setting
Provide routine care when:

The patient feels bestgenerally 17 to 20 days after chemotherapy session

Granulocyte count* is greater than 2000 cells/m

Platelet count* is greater than 50,000 cells/m

If indwelling catheter (or port) is present, administer antimicrobial prophylaxis:

Amoxicillin 2 g 1 hour before procedure or, for patients allergic to penicillin:

Clindamycin 600 mg 1 hour before procedure

Consultation with physician is recommended when values are lower than those listed.

Platelet values below 50,000/m may be associated with significant bleeding.

Osteoradionecrosis
Results from radiation-induced changes (hypocellularity, hypovascularity, ischemia) in the
jaws.
Risk for development of this complication is greatest in posterior mandibular sites and in
patients who have received radiation doses in excess of 6500 cGy to the jaw, those who
continue to smoke, and those who have undergone a traumatic (e.g., extraction) procedure.
If the dentist is unsure of the amount of radiation received and invasive procedures are
planned, the radiation oncologist should be contacted to determine the total dose to the
head and neck region before dental care is initiated (Box 26-13).
Clinicians should be aware that risk of osteoradionecrosis increases with increasing dose to
the jaws (e.g., 7500 cGy is associated with greater risk than 6500 cGy).

Box 26-13
Recommendations to Prevent Osteoradionecrosis in the Patient Undergong
Irradiation of the Head and Neck
1
Extract teeth with questionable and hopeless prognosis at least 2 weeks before
radiotherapy.
2

Avoid extractions during radiotherapy.

Mandible is at greater risk than maxilla.

Posterior sites are at greater risk than anterior sites.

Minimize infection:

Prophylactic antibiotic use: Give 2 g penicillin VK orally 1 hour before surgical

procedure.

After surgery: continue with penicillin VK 500 mg four times a day for 1 week.

Minimize hypovascularity after radiotherapy:

Use non-lidocaine local anesthetic (e.g., prilocaine plain or forte) for dental
procedures.

Minimize or avoid use of vasoconstrictor; if necessary, consider low-concentration

epinephrine (1:200,000 or less).

Consider hyperbaric oxygen therapy.*

Minimize trauma:

Endodontic therapy is preferred over extraction (if the tooth is at all restorable).

Atraumatic surgical technique is essential.

Avoid periosteal elevations.

Limit extractions to two teeth per quadrant per appointment.

Irrigate with saline, obtain primary closure, eliminate bony edges or spicules.

Maintain good oral hygiene:

Use oral irrigators.

Use antimicrobial rinses (chlorhexidine).

Use daily fluoride gels.

Eliminate smoking.

Schedule frequent postoperative recall appointments.