Oral management

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

Give dentures with soft tissue liners to all those

who undergo extractions before or after XRT
 Dental implants in post XRT
patients
Post XRT patients have difficult dental rehab
 Do not have the normal anatomy; may not have a vestibule for
denture flange
 Reconstructed bone may have poor form
Factors before decision for implant placement
 Radiation type, dose, sites, elapsed time since treatment, ?
Protection to bone during XRT, patient’s systemic factors (age,
sex, genetics, smoking, and others)
 Into host mandibular bone, irradiated bone graft or graft that has
been irradiated afterwards
 If XRT dose < 4500 rads, place implants with care
 When > 4500 rads, give 20-30 preop HBO dives and 10 dives
afterwards
 Do not load implants until 6 months after placement
Management of osteoradionecrosis
Most often in mandibles that have received XRT > 6500 rads and
usually not in mandibles that have received < 4800 rads
Severe pain, sequestration and superficial infection
Discontinue wearing any prosthesis and maintain a good state of
oral health
Irrigations to remove debris
Antibiotics not necessarily needed unless superimposed infection is
there (ORN not infection of bone but rather a nonhealing,
hypoxic wound)
↓ vascularity  antibiotic will not reach the wound
Remove loose sequestra but no attempt for a primary closure
1 cm wounds heal; but can take weeks to months
Non healing wounds or extensive ORN, surgical treatment is
indicated
 Resection of involved bone (send for histo to exclude recurrence) with a
margin of unexposed bone and a primary soft tissue closure
 2 better options for reconstruction
Free non vascularized bone grafts with HBO, OR
Free vascularized bone flap with/without HBO
 HBO
100 % O2 delivered in a pressurized
manner in a special purpose cabin
Multi person chamber
 2.4 atm for 90 minutes / dive or session
Single person chamber
 2 atm for 120 minutes / dive or session
Dental management of patients
undergoing chemotherapy
 Effects on oral mucosa
Atrophic thinning of the oral mucosa  painful,
erythematous, and ulcerative mucosal surfaces
in the mouth
 Benzydamine rinses ease discomfort
Mostly on unattached mucosa and rarely on
gingival surfaces
Seen within a week of start of chemotherapy
Spontaneous healing occurs in 2-3 weeks after
stopping of chemotherapy
Effects on hematopoietic system
Myelosuppresion
 Neutropenia, thrombocytopenia and anaemia
 WBC level ↓↓ in 2 weeks after chemo start
Marginal gingivitis
Severe & prolonged neutropenia  severe
infections (overgrowth of organisms esp. fungi)
Thrombocytopenia  spontaneous bleeding
 Platelet transfusion + tranexamic acid; with the
consult of a hematologist
Recovery of myelosuppresion usually completes
in 3 weeks
 Effects on oral microbiology
Overgrowth of indigenous microbes, super
infection with gram –ve bacilli, and
opportunistic infections
Systemic infections cause of 70 % deaths
in patients receiving chemotherapy
Treated concomitantly with anti microbial
agents
 General dental management
Generally the same as for the XRT patient
However, much easier as chemo effects are almost always temporary
and with time, systemic health improves to optimal levels
Chemo for hematologic neoplasm; both disease and therapy lead to a ↓
in functional blood elements
 Patients are at a greater risk for infection or bleeding any time during the
course of their disease
Pre chemotherapy measures
 Prophylaxis, fluoride treatment, and any necessary scaling. Remove
unrestorable teeth
During chemotherapy
 Must maintain good oral hygiene (difficult in mucositis and ulceration)
 Minimum blood values should be:
WBC count 2000 / mm3 (with atleast 20 % leukocytes)
Platelet count 50,000/mm3
 Prophylactic antibiotics if chemo within 3 weeks of dental treatment
 Avoid flossing & use soft tooth brush
 Removable prosthesis to be used with care
 Oral Candidiasis
Topical anti fungals (oral rinses, tablets or creams) with
minimal systemic effects
Persistent infection  continue topical agents in addition
to systemic medications (↓ dose and duration of
systemic administration. Also reduces potential side
effects)
Tablets are slowly dissolving  keep working for a
longer time
Creams for oral commissures and for lining prosthetic
devices
Nystatin x 4 times / day. Should continue for 2 weeks
after end of clinical signs and symptoms
Clotrimazole 4 to 5 times / day
Ketoconazole or fluoconazole in more resistant cases
Chlorhexidine. Potent antibacterial and antifungal
properties; with no potential serious side effects
 Bisphosphonate related
osteonecrosis of the jaws
Bisphosphonates used in a variety of disease conditions
 IV bisphosphonates; metastatic bone deposits from carcinomas,
multiple myeloma
 Oral bisphosphonates; postmenopausal osteoporosis, Paget’s
disease
Have affinity for active hydroxyapatite (↑ bone turnover)
areas, where they do effects on osteoclasts and slow
resorption process
Mandible because of function and frequently performed
dental procedures also forms a centre of active bone area
BRONJ may follow an oral surgical procedure or
spontaneously; far more common in case of IV
bisphosphonates
Treatment; debridement, sequestrectomy and conservative
curettage
Questions?