Describes the oral and general manifestation of radiated patients

1. ORAL & GENERAL MANIFESTATIONS OF RADIATION
AND ITS INFLUENCE IN PROSTHETIC PLANNING
52 1
Presented by:
Dr. Kelly Norton

2. Introduction
52 2

3. Radiation therapy
Electromagnetic
- Photons
Particulate –
Electrons,
protons
neutrons
52 3

4. 52 4
PRIMARY BIOLOGIC EFFECTS OF RADIATION

5. Modalities
52 5
1. CONVENTIONAL RADIOTHERAPY 2. INTENSITY MODULATED RADIOTHERAPY

6. 3. BRACHYTHERAPY
52 6

7. Role of the dentist
• Initial appointment – information source
• To make the patient aware of the short term and long term effects
of radiation
• Manage oral complication after radiation therapy
52 7

8. 52 8
DENTAL MANAGEMENT OF RADIATION THERAPY PATIENTS
1. PRE-RADIATION
2. DURING RADIATION
3. POST RADIATION

9. 52 9
CRITERIA FOR PRERADIATION EXTRACTION
PATIENT RELATED:
1. Residual Dentition
2. Mandible vs maxilla 3. Oral compliance

10. Urgency of treatment
52 10
Prognosis for tumor control
Mode of radiation therapy
RADIATION DELIVERY FACTORS

11. CURRENT EXTRACTION PHILOSOPHIES
52 11

12. 52 12
PROSTHODONTIC ROLE PRIOR TO RADIATION
1. POSITIONING STENT
Goel A, Tripathi A, Chand P, Singh SV, Pant MC, Nagar A. Use of positioning stents in lingual carcinoma patients subjected
to radiotherapy. International Journal of Prosthodontics. 2010 Sep 1;23(5).
Edentulous patientDentulous patient

13. 52
13
2. SHIELDING STENT
CERROBEND ALLOY
Mantri SS, Bhasin AS, Shankaran G, Gupta P. Scope of prosthodontic services for patients with head and neck cancer. Indian
journal of cancer. 2012 Jan 1;49(1):39.

14. 52 14
3. Recontouring stent 4. Radiation positioning device
PRE-LOADED
AFTERLOADED

15. 52 15
5. TISSUE BOLUS DEVICE
Singh BP, Vero N, Singh PK, Verma TR. A simplified technique to fabricate tissue bolus device to manage dose distribution in
maxillectomy patient with orbital exenteration. Journal of oral biology and craniofacial research. 2013 Aug 31;3(2):102-4.

16. 52 16
DENTAL MANAGEMENT DURING RADIATION THERAPY
1. ORAL MUCOUS MEMBRANE
WHO GRADING OF
MUCOSITIS
Dent Clin North Am. 2008 Jan; 52(1): 61–viii.

17. 52 17
PATHOPHYSIOLOGY OF RADIATION MUCOSITIS
Current five-phase pathobiologic model of oral mucositis.
(Reprinted from Sonis ST. A Biological Approach to Mucositis. J Support Oncol 2004; 2:21–36
Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dental Clinics of North
America. 2008 Jan 31;52(1):61-77.

18. 52 18
BACKSCATTER RADIATION
ALTERED ORAL FLORA

19. Palifermin for oral mucositis after intensive therapy for
hematologic cancers
• The aim of this study was to test the ability of palifermin (recombinant human
keratinocyte growth factor) to decrease oral mucosal injury induced by cytotoxic therapy.
• This double-blind study compared the effect of palifermin with that of a placebo on the
development of oral mucositis in 212 patients with hematologic cancers.
• The incidence of oral mucositis of World Health Organization (WHO) grade 3 or 4 was
63 percent in the palifermin group and 98 percent in the placebo group (P<0.001).
• Palifermin reduced the duration and severity of oral mucositis after intensive
chemotherapy and radiotherapy for hematologic cancers
52 19
Spielberger R, Stiff P, Bensinger W, Gentile T, Weisdorf D, Kewalramani T, Shea T, Yanovich S, Hansen K, Noga S,
McCarty J. Palifermin for oral mucositis after intensive therapy for hematologic cancers. New England Journal of
Medicine. 2004 Dec 16;351(25):2590-8.

20. EDEMA
52 20
Tongue-depressing stent in place
Tongue-deviating stent in place
Treatment planning computed tomographic (CT) image with the CTD
stent in place. The planned target volume (PTV) to receive 70 gray of
radiation is shown in red
Johnson B, Sales L, Winston A, Liao J, Laramore G, Parvathaneni U. Fabrication of customized tongue-displacing stents: considerations for use
in patients receiving head and neck radiotherapy. The Journal of the American Dental Association. 2013 Jun 30;144(6):594-600.

21. 52 21
TRISMUS
• 3-6 months after radiation
therapy
• Secondary to fibrosis of the
muscles of mastication
TREATMENT FOR TRISMUS

22. PROSTHETIC REHABILITATION FOR A PATIENT WITH MICROSTOMIA:
A CLINICAL REPORT.
52 22
Gauri M, Ramandeep D. Prosthodontic management of a completely edentulous patient with microstomia: a case report.
The Journal of Indian Prosthodontic Society. 2013 Sep 1;13(3):338-42.

23. Irradiated salivary gland
SALIVARY GLANDS DYSFUNCTION
52 23
•Radiation caries
•Acute and chronic
fungal infections

24. POST-RADIATION SEVERE XEROSTOMIA RELIEVED BY PILOCARPINE:
a prospective study
• The aim of the study was: (1) to confirm the action of pilocarpine hydrochloride (Salagen)
against xerostomia: (2) to correlate the response to dose/volume radiotherapy
parameters.
• From June 1995 to February 1996, 156 patients with severe radiation induced xerostomia
received pilocarpine hydrochloride orally. IS mg per day with a 5 mg optional increase at
S weeks up to a daily dose of 25 mg beyond 9 weeks
• No difference was found according to dose/volume radiotherapy parameters suggesting
that oral pilocarpine hydrochloride: (1) acts primarily by stimulating minor salivary
glands: (2) can be of benefit to patients suffering of severe xerostomia regardless of
radiotherapy dose/volume parameters.
52 24
Horiot JC, Lipinski F, Schraub S, Maulard-Durdux C, Bensadoun RJ, Ardiet JM, Bolla M, Coscas Y, Baillet F, Coche-Dequéant B, Urbajtel M. Post-
radiation severe xerostomia relieved by pilocarpine: a prospective French cooperative study. Radiotherapy and Oncology. 2000 Jun 1;55(3):233-9.

25. Functional salivary reservoir in
maxillary complete denture–
technique redefined
52 25
Joseph AM, Joseph S, Mathew N, Koshy AT..
Functional salivary reservoir in maxillary complete
denture–technique redefined Clinical case reports.
2016 Dec 1;4(12):1082-7.
A 60‐year‐old patient reported to the
Department of Prosthodontics at
Pushpagiri College of Dental Sciences for
the replacement of missing teeth. The
patient also complained of difficulty in
swallowing and mastication and
experienced difficulty in opening his
mouth. The patient gave a history of
radiation therapy 2 months back for focal
keratinizing squamous cell carcinoma.

26. 52 26
Such bone is essentially non vital and is
lacking the capacity for remodeling
BONE CHANGES
IRREGULAR BONY CONTOURS

27. PERIODONTAL CHANGES
52 27
The periodontium is a prime pathway for
infection.
This patient developed an
osteoradionecrosis 4 years
post radiation secondary to
a periodontal abscess

28. DENTAL TISSUE CHANGES
52 28

29. 52 29
OSTEORADIONECROSIS
• Definition – Exposure of bone within the field of radiation of 3 months duration or longer
CLINICAL SYMPTOMS:
Pain
Swelling
Trismus
Exposed Bone
Pathologic Fracture
Orocutaneous fistula formation

30. 52 30

31. • 1. Conservative treatment:
• Irrigation with saline and chlorhexidine
• Iodoform gauze packing
• Gentle debridement with removal of sharp bony spicules.
• Antibiotic coverage if necessary
• PEN-TO-CLO- Pentoxyfylline+ tocopherol+ clodronate
• Strict oral hygiene measures.
52 31
TREATMENT OF OSTEORADIONECROSIS
Robard L, Louis MY, Blanchard D, Babin E, Delanian S. Medical treatment of
osteoradionecrosis of the mandible by PENTOCLO: preliminary results. European
annals of otorhinolaryngology, head and neck diseases. 2014 Dec 31;131(6):333-8.

32. 52 32
• Dr. Marx and his colleagues believe almost all osteoradionecrosis of the mandible
require treatment with hyperbaric oxygen
Hyperbaric Oxygen Therapy
How does HBOT work and why is
it effective ?
 In air, normal 21% oxygen
 100% O2 combined with pressure
delivers 15 times O2 to all body
fluids
 Enhanced growth of new blood
vessels
 Increased ability of white blood
cells to destroy bacteria and
remove toxins
 Increased growth of fibroblasts
(cells involved in wound healing)

33. 52 33

34. Topical Fluoride
• Mouth rinse
• Toothpaste
• Gel applied with custom carriers
52 34
The use of stannous fluoride gel applied with custom carriers and five minute daily
applications.
DENTAL MAINTAINANCE
POST RADIATION CARE

35. ROLE OF ENDODONTIC THERAPY
52 35

36. Examination findings of unique importance
• Condition of oral mucous membranes
• Contours of the bony bearing surfaces, presence of bony
undercuts
• Amount and Viscosity of saliva
• Posterior palatal seal area
• Trismus
• Scarring at the tumor site
52 36
PROSTHODONTIC PROCEDURES
• History findings of importance
• Fields of radiation
• Dose to mandibular bearing surfaces

37. Impressions
• Border molding
• Border mold with a low fusing compound
• Apply petrolatum to prevent sticking to the dry mucosa
• Develop maximum extensions but avoid overextension at
the tumor site
• Do not attempt to displace the floor of the mouth to
obtain peripheral seal.
52 37Thermoplastic wax
Polysulfide
• Wash impression materials

38. Assessment of Vertical dimension
• Determined by phonetics, closest speaking
space, swallowing , VDR
• The VDO is reduced only in patients with
severe trismus so as to facilitate easy entrance
of the bolus by increase in interocclusal space.
• In case of severe scarring of tongue, lower the
occlusal plane
52 38

39. Centric relation records are
made in the usual manner
using wax, ZOE or silicone
materials
• A facebow transfer record is used to mount the maxillary cast on the articulator.
52 39

40. Lingualized / bilateral balance
52 40
Nonanatomic with balancing ramps
• Less horizontal forces are generated
• Proper horizontal overlap to maintained
Occlusal forms

41. Delivery and Post-Insertion Care
• Pressure indicating paste
• Disclosing wax- delineate overextension
• Clinical remount
• 24 and 48 hour follow up
• Leave dentures out at night
• Educate the patient
52 41

42. Period between Completion of Radiation Therapy and Prosthetic Rehabilitation in Edentulous
Patients: A Retrospective Study
Purpose:
1. to describe the number and types of complications patients had before and after insertion of a
removable prosthesis (i.e., denture) following radiation therapy to the head and neck and
2. to investigate whether the time between radiation therapy and denture insertion might contribute to
those complications
Materials and Methods: A total of 190 patients met the inclusion criteria with data available for review.
Conclusions:
• The majority of patients had no complications.
• The patients who received their dentures in 180 days or less had the same number of complications when
compared with those patients who received their dentures in 181 to 365 days and those who had to wait
longer than a year for prosthetic rehabilitation.
• Patients with more pre-insertion complications tended to have delayed prosthetic rehabilitation.
• The majority of patients who experienced complications before and after denture insertion had greater
than 5000 cGy.
52 42
Period between Completion of Radiation Therapy and Prosthetic Rehabilitation in Edentulous Patients: A Retrospective Study Peter J. Gerngross, et al . J
Prosthodont 2005;14:110-121

43. Implants in irradiated tissues
• Radiation effects :
• Reduced vasculature
• Loss of osteo progenitor cells
• Fatty degeneration
• Compromised remodeling
• Susceptibility to
osteoradionecrosis
52 43
Root
surfac
e
Marrow
Trabecular bone
• Loss of central artery in
Haversian systems
• Death of osteocytes

44. Implants in the irradiated maxilla
• Predictability-Maxilla %Success
• Roumanas et al, 1998 55
• Nimi et al, 1998 63
52 44
Without HBO
Implants in irradiated edentulous maxillectomy patient (UCLA Data)
Patients Number of implants Success
Treated placed uncovered buried failed %
Irradiated 13 50 29 11 10 55.2

45. 52 45
In the mandible, one would expect risk to become significant at
doses to bone above 6500 cGy. This patient received 6600 cGy for a
squamous carcinoma of the lateral tongue. Three years later implants
were placed.
Eventually, the patient developed an osteoradionecrosis, a pathologic fracture
of the mandible and subsequently the mandible was resected.
Three years after implant
placement the patient
developed an infection
associated with left posterior
implant.
Implants in the irradiated mandible

46. IMPLANTS IN THE CRANIOFACIAL SITES
Success is poor and failures are late because:
• Anchorage is mechanical: short implants have
higher failure rate
• Exposure of flange leads to persistent irritation of
perimplant skin or mucosa
52 46
Flange exposure Eventually led to loss of implants

47. IRRADIATION OF EXISTING IMPLANTS
52 47
These implants were
irradiated 2 years
following placement.
Note the exposure of the
implant flanges.
Recommendation:
Abutments and superstructures should be removed
and skin and/or mucosa closed over the implant
fixtures prior to radiation.

48. SUMMARY
• Implant material : Advanced dental implant surfaces like TPS [titanium plasma spreaded],
SLA [sandblasted and acid etched], Ti-Unite and different implant materials like zirconia
[zirconium oxide]
• Implant position : Implants can be best placed in the mandibular anterior / symphyseal region
as it is the area which receives the least amount of radiation. The maximum implant failures are
reported in the maxillary jaw [69% to 95%] .
• Type of prosthesis : Fixed implant supported prosthesis is advocated in irradiated mandibles.
• Effect of radiation dose :. Favorable osseointegration is found in radiation doses lesser than
45-50 Gy.
• Effect of smoking: Irradiated patients who continued to smoke must be considered as an
absolute contraindication to treatment.
52 48Dholam KP, Gurav SV. Dental implants in irradiated jaws: a literature review. Journal of cancer research and therapeutics. 2012
Jan 1;8(6):85.

49. • Soft tissue complications : Gingivitis was more common in these patients than normally
observed. Cover-screw mucosal perforations were observed over the areas of 17% of
implants during the healing period between stage one and stage two surgery.
• Hyperbaric oxygen : Some studies found it useful while others considered it as an
additional burden of treatment.
Timing of implant placement: One year time interval between tumor therapy and the time
of dental implantation seems logical
• Timing of abutment placement and loading the implants: Abutment connection,
fabrication and loading of the prosthesis should be delayed for six months instead of the
traditional three to four months to permit osseointegration.
52 49
Dholam KP, Gurav SV. Dental implants in irradiated jaws: a literature review. Journal of cancer research and therapeutics. 2012
Jan 1;8(6):85.

50. Osseointegrated implants in irradiated bone: A case-controlled study using adjunctive
hyperbaric oxygen therapy
• The current investigation was undertaken to study whether osseointegration of implants in
irradiated tissues is subject to a higher failure rate than in non irradiated tissues. It further aimed
to study whether hyperbaric oxygen treatment (HBO) can be used to reduce implant failure.
• Patients and Methods:
• 78 cancer patients who were rehabilitated using osseointegrated implants between 1981 and 1997
were investigated. Three groups of patients were compared: irradiated (A), nonirradiated (B), and
irradiated and HBO-treated (C). In addition, 10 irradiated patients who had lost most of their
implants received new ones after HBO treatment. These were compared as a case-control group.
• Conclusions: Implant insertion in irradiated bone is associated with a higher failure rate. Adjuvant
HBO treatment can reduce the failures.
52 50
Granström G, Tjellström A, Brånemark PI. Osseointegrated implants in irradiated bone: a case-controlled study using adjunctive
hyperbaric oxygen therapy. Journal of oral and maxillofacial surgery. 1999 May 1;57(5):493-9.

51. 52 51
The aim of this systematic review was to evaluate the effect of radiation therapy on osseointegrated
dental implant survival in oral cancer patients.
MATERIALS AND METHODS:
A review of the literature published between 1990 and June 2012 was conducted. Overall implant
survival rates were compared with respect to timing of radiation ,site of implant placement, radiation
dose, time interval between radiation therapy and implant placement, and the effect of hyperbaric
oxygen therapy.
CONCLUSION:
There, was no significant difference in dental implant survival rates between pre implantation and
post implantation radiation therapy. The anatomical site of implant placement in preimplantation
radiation therapy was the most pertinent variable affecting implant survival, with a better survival
rate in the mandible compared to the maxilla and grafted bone.
Dental implant survival in irradiated oral cancer patients: a
systematic review of the literature.
Nooh N. Dental implant survival in irradiated oral cancer patients: a systematic review of the literature. International Journal of Oral &
Maxillofacial Implants. 2013 Sep 1;28(5).

52. Implant-prosthetic rehabilitation after radiation treatment in head and neck cancer
patients: a case-series report of outcome.
• The aim of the study was to review the
outcome of implant-prosthetic treatment
after radiation therapy.
• Patients and methods. Twenty irradiated
head and neck cancer patients received a
removable implant supported denture
• Results. Twenty patients had 100 implants
inserted. The estimated implant survival
rate was 96% after 1 year and 87% after 5
years. Failures were mostly observed
before loading (91.2%). The attachment
system and the number of implants did
not have a statistically significant
influence on the success rate.
52 52
Conclusions. Implant-supported dentures have been
shown to be a reliable treatment modality after head and
neck cancer surgery and radiation therapy. Possible early
failures should be communicated with the patients
Cotic J, Jamsek J, Kuhar M, Ihan Hren N, Kansky A, Özcan M, Jevnikar P. Implant-prosthetic rehabilitation after radiation treatment in
head and neck cancer patients: a case-series report of outcome. Radiology and oncology. 2017 Mar 1;51(1):94-100.

53. Conclusion
52 53
In summary, it is our intention and goal as dentists to minimize and/or prevent
potentially devastating side effects of Radiation therapy from occurring and to
help the patient maintain the highest possible level of oral health and function
both during and after Radiotherapy.

54. REFERENCES
52 54
1. Beumer J, Curtis T, and Nishimura R. Prosthetic management - Edentulous patients. In
Beumer J, Curtis T, and Marunick M, editors. Maxillofacial Rehabilitation. St. Louis –
Tokyo: Ishiyaku EuroAmerica 1996.
2. Thomas T Taylor , Clinical Maxillofacial Prosthetics, First edition,2000, Quintessence
publications, Illionis, pp 37 – 52
3. Goel A, Tripathi A, Chand P, Singh SV, Pant MC, Nagar A. Use of positioning stents in
lingual carcinoma patients subjected to radiotherapy. International Journal of Prosthodontics.
2010 Sep 1;23(5).
4. Mantri SS, Bhasin AS, Shankaran G, Gupta P. Scope of prosthodontic services for patients
with head and neck cancer. Indian journal of cancer. 2012 Jan 1;49(1):39.
5. Singh BP, Vero N, Singh PK, Verma TR. A simplified technique to fabricate tissue bolus
device to manage dose distribution in maxillectomy patient with orbital exenteration. Journal
of oral biology and craniofacial research. 2013 Aug 31;3(2):102-4.
6. Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer.
Dental Clinics of North America. 2008 Jan 31;52(1):61-77
7. Spielberger R, Stiff P, Bensinger W, Gentile T, Weisdorf D, Kewalramani T, Shea T, Yanovich
S, Hansen K, Noga S, McCarty J. Palifermin for oral mucositis after intensive therapy for
hematologic cancers. New England Journal of Medicine. 2004 Dec 16;351(25):2590-8

55. 8. Johnson B, Sales L, Winston A, Liao J, Laramore G, Parvathaneni U. Fabrication of
customized tongue-displacing stents: considerations for use in patients receiving head
and neck radiotherapy. The Journal of the American Dental Association. 2013 Jun
30;144(6):594-600.
9. Gauri M, Ramandeep D. Prosthodontic management of a completely edentulous patient
with microstomia: a case report. The Journal of Indian Prosthodontic Society. 2013 Sep
1;13(3):338-42.
10. Horiot JC, Lipinski F, Schraub S, Maulard-Durdux C, Bensadoun RJ, Ardiet JM, Bolla
M, Coscas Y, Baillet F, Coche-Dequéant B, Urbajtel M. Post-radiation severe
xerostomia relieved by pilocarpine: a prospective French cooperative study.
Radiotherapy and Oncology. 2000 Jun 1;55(3):233-9.
11. Joseph AM, Joseph S, Mathew N, Koshy AT.. Functional salivary reservoir in maxillary
complete denture–technique redefined Clinical case reports. 2016 Dec 1;4(12):1082-7.
12. Robard L, Louis MY, Blanchard D, Babin E, Delanian S. Medical treatment of
osteoradionecrosis of the mandible by PENTOCLO: preliminary results. European
annals of otorhinolaryngology, head and neck diseases. 2014 Dec 31;131(6):333-8.
13. Period between Completion of Radiation Therapy and Prosthetic Rehabilitation in
Edentulous Patients: A Retrospective Study Peter J. Gerngross, et al . J Prosthodont
2005;14:110-121
14. Dholam KP, Gurav SV. Dental implants in irradiated jaws: a literature review. Journal
of cancer research and therapeutics. 2012 Jan 1;8(6):85.
52 55

56. 15. Granström G, Tjellström A, Brånemark PI. Osseointegrated implants in irradiated bone:
a case-controlled study using adjunctive hyperbaric oxygen therapy. Journal of oral and
maxillofacial surgery. 1999 May 1;57(5):493-9.
16. Nooh N. Dental implant survival in irradiated oral cancer patients: a systematic review
of the literature. International Journal of Oral & Maxillofacial Implants. 2013 Sep
1;28(5).
17. Cotic J, Jamsek J, Kuhar M, Ihan Hren N, Kansky A, Özcan M, Jevnikar P. Implant-
prosthetic rehabilitation after radiation treatment in head and neck cancer patients: a
case-series report of outcome. Radiology and oncology. 2017 Mar 1;51(1):94-100.
52 56