The document discusses dental complications from head and neck radiotherapy, including changes to taste, xerostomia, salivary gland damage, oral infections like candidiasis, rapid dental decay, osteoradionecrosis, and recommendations for preventive dental care before, during, and after radiation therapy to minimize complications and promote oral health. A multidisciplinary approach between dentists and radiation oncologists is emphasized to plan treatment, monitor oral health issues, and provide ongoing dental care and patient education.

2. DENTAL COMPLICATIONS OF HEAD
& NECK RADIOTHERAPY
Multidisciplinary approach in cancer treatment
Dental care: early in the patient’s treatment
Aims of dental care:
- To prevent
- To reduce side effects of radiotherapy
- To promote good oral health post-radiation

3. Dental complications of head &
neck radiotherapy

6. All 4 taste are affected:
- Salty sensation : all over the tongue
- Sweet sensation : anterior surface & tip of the tongue.
- Sour sensation : lateral surfaces.
- Bitter sensation : circumvallate papillae
Xerostomia & Radiation-induced damage to taste
buds -> Hypogeusia (2 wks after the start of
radiotherapy) -> Ageusia
-> partially restored 20-60days & fully restored 2-4
months post-radiation.
> 60 Gy: permanent loss of taste.

7. Radiation-induced salivary gland acinar cell
inflammation, fibrosis & degeneration
6 - 10 Gy: Hyposaliva
Restored 6-12 months post-radiation.
But not restored if > 50 Gy, no saliva if >70 Gy.
Alteration of oral environment (candidiasis,
dental caries, dysphonia, dysphagia) -> potentially
serious systemic consequences (malnutrition).

8. !
1. Candidiasis
Most common infection during radiotherapy,
post-radiation, esp. With persistent xerostomia.
Acute: erythema, burning sensation,
mistaken for radiation mucositis.
Chronic: most common in corners of mouth.
2. Cariogenic microorganism (S. mutans,
Lactobacillus, Actinomyces,…) predominate

9. Clinically distinctive pattern:
1. Smooth surfaces are the 1st affected:
Circumferential caries at the ementoenamel
junbction.
2. Caries in many sufaces of a tooth, in many teeth
3. Caries progression are fast.

10. Teeth
Xerostomia -> polycaries.
Decalcification ???
Dental pulp: decrease in vascularity with
fibrosis & atrophy -> decrease in response to
infection, trauma, yet pulpal pain is less severe.
Tooth development:
Prior to calcification: destroy tooth bud.
Late stage of dev.: arrest growth, enamel &
dentine irregularities.

11. Circumferential
caries at the
cementoenamel
junction
-> crown amputation

12. Osteoradionecrosis (ORN)
An irreversible, progressive devitalisation of irradiated
bone.
A bone ischemic necrosis caused by radiation.
One of the most serious sequences of radiotherapy.

13. Pathophysiology of ORN
1922 Regaud
1926 Ewing: Osteomyelitis in irradiated bone
1971 Titterington: Osteomyelitis secondary to
irradiation
1970 Meyer: Radiation+Trauma (initiator)+Infection
1983 Marx:
Microorganism may not play a pivotal role.
ORN is not a primary infection of irradiated bone
Spontaneous ORN may be related to higher radiation
dose.
However, where trauma is associated with ORN, it is
caused by tooth removal (88%).

14. “3H” Tissue
Hypovascular
Hypocellular
Hypoxic

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20. Team work: Radiation Therapy (RT)
1. Determination of radiation:
- Fields
- Dose, how much to the jaw bones,
- Salivary glands included in the RT field
2. Dental therapy based on RT plan
3. Patient education about oral complications
4. Discussion of the importance of oral hygiene.

21. ORAL MANAGEMENT OF THE CANCER PATIENTS
Prior to head and neck radiation therapy
1. Extraoral examination: face, neck
Intraoral exam: lip, buccal mucosa, gingiva, tongue, floor, palate
2. Diagnosis of dental treatment: Panorex diagnosis, evaluation of
dental caries, calculus & periodontal disease, endodontic &
mucosa lesions.
3. Dental treatment: Extraction - Prosthetic surgery – Caries removal,
Smoothing of any rough or sharp surfaces - Calculus removal
4. Prevent tooth demineralization and radiation caries: daily fluoride
5. Oral hygiene instruction
6. Tobacco & alcohol cessation, dietary counseling

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Indications:
1. Root fragment or advanced caries
2. Bone pathology: periapical infection
3. Advanced periodontitis
4. Furcation involvement
5. Erupting or unrupted teeth causing complication
At least 14 days for tissue healing prior to radiotherapy
(usually 14-21 days).

25. ORAL MANAGEMENT OF THE CANCER PATIENTS
During radiation therapy
1. Monitor patient’s oral hygiene
-Keep mouth moist & clean. Treat infections
2. Dietary counseling
3. Monitor patient for Trismus:
- Check for pain or weakness in masticating muscles.
- Exercise 3 times/day X 20 times, opening as far as possible.

27. After radiotherapy
Frequent Dental follow-up to reinforce palliative &
preventive measures: Recall for the first 1-2 or 3
months, 6 months & 1 year.
At each visit:
- Check for mucositis (only 2-3 wks), xerostomia,
demineralization & caries, signs of infection, trismus,
recurrent tumor.
- Emphasize oral hygiene
Daily fluoride treatment:
1.1 % neutral sodium fluoride gel for 5 minutes/day.
0.4 % stannous fluoride gel

34. How to Use Custom Fluoride Carriers (Trays)
At bedtime, Place a thin ribbon of the fluoride gel into each
tray so that each tooth space has some fluoride. The
fluoride can be spread into a thin film that coats the inside
of the trays, by using a cotton-tipped applicator, finger or
toothbrush.
Seat the trays on the upper and lower teeth and let them
remain in place for 5 minutes.
After 5 minutes, remove the trays and thoroughly
expectorate (spit out) the residual fluoride. Very Important
- do not rinse mouth, drink or eat for at least 30
minutes (1 hour if possible) after fluoride use.
For head and neck radiation patients, begin using fluoride in
the custom trays no longer than one week after
radiotherapy is completed. Repeat daily for the rest of
your life!!
Remember that tooth decay can occur in a matter of
weeks if the fluoride is not used properly.

35. Care for Fluoride Carriers (Trays)
Rinse and dry the trays thoroughly after each use.
Clean them by brushing them with a toothbrush
and toothpaste.
Occasionally, the trays can be disinfected in a
solution of sodium hypochlorite (Clorox) and
water. Use one tablespoon of Clorox in about one-
half cup of water. Soak them for about 15 minutes.
If the trays become covered with hard water
deposits, soak them in white vinegar overnight
and brush them the next morning.
Do not boil the trays or leave them in a hot car as
they may warp or melt.
Pamela Sandow, University of Florida College of Dentistry

36. After radiation therapy
Mucositis
- Rinse mouth with salt/bicarbonate
¼ tsp baking soda & 1/8 tsp salt in 1 cup of warm water,
several times a day.
- 2% viscous lidocaine, analgesics
- Sip water
- Avoid highly seasoned and coarse foods.
- Avoid trauma (use soft-bristle toothbrush)
- Maintain good oral hygiene

37. Oropharyngeal Candidiasis
Risk: myelosuppresion, mucosal injury, salivary compromise, steroids
Diagnosis: history, risk factors, examination, culture as needed.
Treatment:
1. Topical antifungal agents (systemic if indicated)
. Clotrimazole troche (10 mg) 4-5 times/day
. Nystatin oral suspension (100,000 U/ml): 5 ml, 4 times/d
. Nystatin pastilles (200,000 U) 4-5 times/d
. Fluconazole solution (e.g. 10 mg) swish 3 times/d
. Amphotericin B oral suspension (100 mg/ml) 1 ml, 4 times/d
2. Nonmedicated oral rinse
3. Remove dentures, Nystatin ointment for denture wearers

38. After radiation therapy
Management of the Xerostomic Cancer Patients
- Sialogogues: pilocarpine HCl, sulfarlem S25
- Saliva substitutes (spray or gel)
- Sip water or sugar-free liquid, use sugar-free
candy
- Lifelong, daily applications of topical high
concentration fluoride gel.
- Avoid mouth rinse with alcohol
- Antimicrobials

40. & !
Dental filling
Use topical Fluoride daily (15 min X 3 times/day)
Antimicrobials: eg. Chlorexidine
Treatment of xerostomia
Frequent recall visits
Refrain from taking sugar containing food & drink.

41. & !
Radiation & postradiation physical therapy
inlcuding range-of-motion exercises.

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45. HBO Appointment Protocol
2-2.5 atmospheres pressure for 90 minutes per day
Each treatment takes ~ 130 minutes
• 10 minutes - pressurization
• 30 minutes - 100% oxygen
• 5 minutes - air break
• 30 minutes - 100 % oxygen
• 5 minutes - air break
• 30 minutes - 100% oxygen
• 20 minutes - depressurization 1.3 ATA

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60. New Technology:
Intensity Modulation Radiotherapy
IMRT

61. Higher total dose (65 Gy) & dose per fraction (2.17 Gy) to the
primary tumor and involved nodes (red in 3D reconstruction and
green color wash)
Lower total (54 Gy) dose and dose per fraction (1.8 Gy) to the
elective nodes (purple in 3D reconstruction & orange color wash).

62. Parotid gland sparing intensity-modulated radiotherapy (IMRT):
A dose distribution to deliver a high dose to the target volume (blue
contour and red colour wash) whilst sparing the parotid gland (pink
contours) can be achieved with IMRT.

63. Comparison between conventional and intensity-modulated post-
operative radiotherapy for stage III and IV oral cavity cancer in terms of
treatment results and toxicity
Wen-Cheng Chen, Oral Oncology 2008
The aim of this study was to assess the treatment results and toxicity profiles of post-
operative conventional radiotherapy (Conv-RT) and IMRT for stage III and IV oral
cancer. During the period from 4/2002 to 12/2005, a total of 49 patients with stage III
and IV OSCC were treated with radical surgery followed by post-operative RT. 27
patients received Conv-RT while 22 received IMRT. Only 3 patients received
adjuvant chemotherapy. With a median follow-up time of 3.3 years, the 3-year overall
survival and disease-free survival rates for patients who received Conv-RT vs IMRT
were comparable.
There was no significant difference in acute toxicity between the two
different RT techniques. However, in terms of late toxicity, patients receiving
IMRT had significantly less moderate to severe xerostomia and
dysphagia than those receiving Conv-RT (36% vs 82%, p = 0.01 for
xerostomia and 21% vs 59%, p = 0.02 for dysphagia). Post-operative Conv-
RT and IMRT are equally effective in terms of tumor control for locally
advanced oral cavity cancer. Patients receiving IMRT had comparable acute
and significant less late toxicity than those receiving Conv-RT.

64. 32 yearld old, female
2000: Tonsil cancer -> Radiotherapy 70 Gy
2004: ORN -> hemimandibulectomy (left)

65. 2004: Dental caries -> HBO 20 times +
extraction upper teeth and root canal treatment
lower teeth
2008: ORN stage 2 (right)-> treatment???

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