Management of Patient Undergoing Radiotherapy or Chemotherapy

Dental Management of Patients undergoing Radiotherapy to Head and neck

Normal tissues with rapid turnover rates are affected by radiation

Hematopoietic cell
Epithelial Cell
Endothelial Cells

Radiation effects on Oral Mucosa

	Management/Notes
Mucositis with or without ulceration	Antibiotic Lozenges containing amphotericin, tobramycin and neomycin Viscous Lidocaine
Loss of sense of taste	gradually returns, depending on the quantity and quality of saliva that remains after treatment
Delayed healing	Thin and less keratinized epithelium
Pale appearance to tissue	Submucosa is less vascular
Radiotherapy induced submucosal fibrosis	Lining of oral cavity is less pliable and less resilient
Ulcerations	Take week or months to heal

Radiation Effects on Mandibular Mobility

Management/Notes

Trismus

Inflamed pterygo-masseteric sling and periarticular CT -> resultant fibrosis and tends to contract, degeneration of articular surface

interincisal opening decreases to 20mm

Difficult food intake

May require GA for dental treatment

Radiation Effects on Salivary Glands

	Notes
Xerostomia	Destruction of fine vasculature by radiation -> resultant atrophy, fibrosis and degeneration
Oral Complications of Xerostomia	Difficulty tasting, chewing and dysphagia Difficulty sleeping Esophageal dysfunction Nutritional compromises Glossitis, Candidiasis, Angular Cheilitis, halitosis, bacterial sialadenitis Rampant caries Increased susceptibility to mucosal injury
Management of Xerostomia	Sipped water throughout the day Sipping water during meals Saliva substitutes (eg. Saliva ions and glycerin, carboxymethylcellulose) Avoid alcohol or strong flavors containing products Avoid sugar containing products Avoid Caffeine and OTC antihistamines & decongestants (decrease production of saliva) Sugar free chewing gum Parasympathomimetic agents – stimulate secretion of exocrine gland Tab Pilocarpine 5mg QID Tab Cevimeline 30mg TID

Radiation Effects on Bone

	Notes
Osteoradionecrosis	Devitalization of bone by cancericidal doses of radiation Elimination of fine vasculature within bone Decreased turnover rate and remodelling process Mandible is most commonly affected Less vascular Denser bone

Candidiasis

Topical Nystatin
Clotrimazole 10mg Lozenges – suck 1 loz 5 times a day

Evaluation of Dentition before Radiotherapy – Pre-irradiation extraction

Condition of residual dentition
Questionable or poor prognosis teeth – Extract
Patient’s Dental Awareness
Immediacy of Radiotherapy
Radiation Location – Allow extraction site to heal for 1-2 weeks
Radiation Dose

Preparation of Dentition for Radiotherapy and Maintenance after Irradiation

Before Radiotherapy

Full mouth fluoride varnish
Perform Prophylaxis
Oral Hygiene Instructions
Round off any sharp cusps
Smoking Cessation
Alcohol Cessation

During Radiotherapy

Saline mouth rinse at least 10 times a day
Chlorhexidine mouth rinse twice a day
Observation and oral hygiene evaluation each week
Monitor patient’s ability to open mouth
Physiotherapy to maintain pre-irradiation interincisal dimension
Weighed weekly to monitor nutritional status

After Radiotherapy

Follow-up every 3-4 months
Perform Prophylaxis
Full mouth fluoride varnish
1% Fluoride mouth rinse for 5 minutes each day
Mouth-opening exercises, Jaw-exercising applications

Methods of Performing Pre-irradiation Extractions

Atraumatic exodontia
Smooth any boney edges
Prophylactic Antibiotics

Interval between Pre-irradiation Extractions and Beginning of Radiotherapy

3 weeks after extraction – to ensure sufficient soft tissue healing

Methods of managing carious teeth after radiotherapy

Composite or amalgam
Full Crowns – not recommended as recurrent caries is more difficult to detect
Oral Hygiene instructions
Topical Fluoride Application

Following Cancer Therapy

	Management
Limited Mouth Opening	Ensure that it is not due to local recurrence, metastatic lesions in the head and neck region and/or a second malignant lesion Jaw Exercises Stacked Tongue Spatulas Jaw Opening devices
Growth and Development	Dental Development abnormalities in childhood cancers Microdontia Tooth Agenesis Xerostomia
Fungal Infections	Nystatin oral suspension 100 000 units per ml QID 2/52 OR Topical Miconazole Gel 24mg/ml 10ml QID 2/52 OR Cap Fluconazole 50mg QID 2/52 Note Miconazole and fluconazole are contraindicated in patients taking warfarin or statin Increases INR value – Miconazole and Fluconazole are inhibitor of P450 isoenzyme CYP2CP which are involved in warfarin metabolism Statins – increase risk of myopathy and rhabdomyolysis Denture Denture hygiene Cleaned with toothbrush and soaked in chlorhexidine mouthwash Apply miconazole oral gel on the fitting surface of denture
Mucositis	Benzydamine Hydrochloride 0.15% mouthwash 15ml QID 2% lidocaine gel/mouthwash before eating
Xerostomia	Fluoride Supplementation Lubrication of soft tissue – Vaseline Salivary Stimulants Tab Pilocarpine 5mg TID Sugar free chewing gum Salivary Substitution Frequent sips of water Content – Sodium Carboxymethylcellulose, Xantham gum, Sodium fluoride, , Sorbitol Dietary Advice Avoid Hard food, spicy food, strongly flavoured toothpaste Alcohol, tobacco Fizzy drinks, acidic fruit and fruit drinks
ORN	Prophylactic Antibiotic 1 hour before procedure Çontinue Tab Amoxicillin 500mg TID for the next 7 days http://www.e-mjm.org/2002/v57n2/Osteoradionecrosis.pdf Patients are at particular risk of ORN when: The total radiation dose exceeded 60Gy (Nabil and Samman, 2011) (Clayman, 1997) The dose fraction was large with a high number of fractions. There is local trauma as the result of a tooth extraction (especially mandibular extractions), uncontrolled periodontal disease or an ill-fitting prosthesis. The person is immunodeficient. The person is malnourished . Staging of ORN Stage 0 – mucosal defects; only bone exposed Stage 1 – radiological evidence of necrotic bone, dento-alveolar only Stage 2 – positive radiographic findings above ID canal with denuded bone intraorally Stage 3 – clinically exposed radionecrotic bone, verified by imaging techniques, along with skin fistulas and infection with addition of potential or actual pathological fracture. Radiological evidence of bone necrosis within the radiation field, where tumor recurrence has been excluded.
Medication-related osteonecrosis (MRONJ)	Bisphosphonates or anti-resorptive agents Staging of MRONJ At Risk: No apparent necrotic bone in patients who have been treated with oral or intravenous bisphosphonates Stage 0: No clinical evidence of necrotic bone but nonspecific clinical findings, radiographic changes, and symptoms Stage 1: Exposed and necrotic bone or fistulas that probes to bone in patients who are asymptomatic and have no evidence of infection Stage 2: Exposed and necrotic bone or fistulas that probes to bone associated with infection as evidenced by pain and erythema in the region of exposed bone with or without purulent drainage Stage 3: Exposed and necrotic bone or a fistula that probes to bone in patients with pain, infection, and ≥ 1 of the following: exposed and necrotic bone extending beyond the region of alveolar bone (i.e. inferior border and ramus in mandible, maxillary sinus, and zygoma in maxilla) resulting in pathologic fracture, extraoral fistula, oral antral, or oral nasal communication, or osteolysis extending to inferior border of the mandible or sinus floor