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of patients undergoing
radiotherapy and chemotherapy
Adnan Aslam
Registrar, Oral & Maxillofacial Surgery
Islamic International Dental College
Islamabad
Radiation therapy (XRT) for head &
neck cancer
Ideally, XRT should destroy neoplastic cells while
sparing normal cells
In reality, this is not achieved normal tissues
experience some undesirable effects
XRT can destroy any neoplasm if XRT is of sufficient
dose (Limited by the amount of XRT normal adjacent
tissue can tolerate)
XRT destroys cells (neoplastic and normal) by
interfering with nuclear material necessary for
reproduction, cell maintenance, or both
Faster cellular turnover More susceptible to XRT
Faster turnover cells are neoplastic cells, but also
hematopoietic cells, epithelial cells, and endothelial cells
Radiation effects on oral mucosa
Erythema first 1-2 weeks
Severe mucositis +/- ulceration
Pain & dysphagia adequate nutritional intake becomes
difficult
XRT ends begin to subside
Loss of taste
Long term effects
Predisposition to breakdown & delayed healing
Epithelium is thin and ↓ keratinized
Submucosa is ↓ vascular (pale appearance of tissue)
OSF mucosal lining is less pliable & less resilient
Even minor trauma ulcerations that takes weeks/months to heal
(often difficult to differentiate from recurrent disease)
Radiation effects on salivary glands
↓ turnover rate (? Radioresistant)
However, destruction of fine vasculature
atrophy, fibrosis, and degeneration
Xerostomia; ‘dry mouth’
↓ saliva rampant ‘radiation caries’
swift destruction of teeth with severe
infections of jaws
Circumferential cervical decay
Periodontitis
Dysgeusia, dysphonia, and dysphagia
Treatment of Xerostomia
Frequent sipping of water throughout the
day
Artificial saliva preparations contain ions
and lubricants (i.e. glycerin) but not
protective proteins
Sialagogues (parasympathomimetic
agents working as muscarinic agonists)
Pilocarpine HCl. 5 mg x q6h
Cevimeline HCl. 30 mg x q8h
Radiation effects on bone
Osteoradionecrosis (ORN)
Devitalization of bone by cancericidal doses of
radiation
3 Hs
Hypovascular
Hypoxic
Hypocellular
Endarteritis elimination of fine vasculature bone
becomes virtually nonvital bone turnover so slow
that self repair becomes ineffective
Mandible ↑ than maxilla
Other effects of XRT
Alteration in normal oral flora
overgrowth of anaerobic species and fungi
Commonly, Candida albicans
? By radiation or xerostomia?
Nystatin topical application
0.1% chlorhexidine mouth rinse (potent anti
bacterial and anti fungal effects)
Dental evaluation before XRT
Condition of residual dentition
Extract all teeth with questionable or poor prognosis (endo or perio)
May not be in keeping with usual dental principles, however
When in doubt, extract
Patient’s dental awareness
Excellent oral hygiene and health retain as many teeth as possible
Otherwise, extract
Immediacy of XRT
XRT location
Salivary glands and bone involved in line of XRT?
Combination of xerostomia and irradiated bone
Can XRT wait for 1-2 weeks?
XRT dose
Higher the radiation dose, more severe is normal tissue damage
OSCC requires 6000 rads (cGy)
When dose below 5000 rads xerostomia & ORN are dramatically
reduced
Dental preparation & maintenance
for XRT
Before treatment
Decide which teeth are healthy enough to be maintained
Carefully inspect for pathological conditions & restore to the best state of health obtainable
Topical fluoride application
Demonstrate and reinforce oral hygiene measures and instructions
Round off sharp cusps
Take impressions for peri XRT fluoride trays
Encourage giving up tobacco use and alcohol consumption
During treatment
Rinse the mouth atleast ten times/day with saline
Chlorhexidine mouth washes x 2 times/day minimize bacterial and fungal levels
See patient every week for observation and oral hygiene instructions
Overgrowth of candida topical nystatin or clotrimazole
Observe mouth opening for fibrosis (in masticatory muscles) effects physiotherapy
to maintain mouth opening
Weigh weekly (? Adequate nutritional status) oral dietary intake difficult due to
combination of mucositis and xerostomia feed with NG tube, if needed
After treatment
See every 3 to 4 weeks
Topical fluoride applications daily self administration of fluoride OR 1 % fluoride
rinse for five minutes each day
Pre XRT extractions
No bone preservation in exodontia related to pre XRT extractions
Remove a good portion of alveolar process achieve primary closure
Once XRT starts normal remodeling process gets inhibited sharp
bony edges will cause ulceration with bone exposure
Handle mucoperiosteal flap atraumatically
Use burs or files to smooth the bony edges under copious irrigation
Give prophylactic antibiotics
The wound should heal before the XRT is given If XRT is given
before wound healing, healing will be delayed and will take months
or even years
Traditionally, 7 -14 days before extractions/extractions + surgery and
XRT
Ideally should be delayed for three weeks
If wound dehiscence occurs in between give daily local wound
care
3M extract if partially erupted. Leave if totally within the bone
Carious teeth after XRT
Composites and amalgam restorations
? Probably not full crowns underneath
caries may be difficult to detect
Reinforce oral hygiene measures
Necrotic pulp do endodontics with systemic
antibiotics. Also grind the tooth out of
occlusion
If RCT is difficult because of root canal sclerosis,
amputate tooth above gingiva and leave in place
Tooth extraction after XRT
Use systemic antibiotics
Either nonsurgical extraction OR surgical
extraction with alveoloplasty and primary closure
HBO before and after tooth extraction
Increase local oxygenation & vascular ingrowth into
hypoxic tissues
Protocol. 20-30 dives (in 4-6 weeks) before
extractions & 10 dives (in 2 weeks) after extractions