This document discusses dental considerations for patients undergoing radiation therapy. It covers the immediate and delayed effects of radiation on oral tissues, including mucositis, xerostomia, candidiasis, trismus, and osteoradionecrosis. Management strategies are provided for each complication. Radiotherapy prostheses are described that protect healthy tissues, improve treatment accuracy, and enhance patient comfort during radiation. Factors affecting radiation damage and the role of hyperbaric oxygen therapy in managing osteoradionecrosis are also summarized.

1. Dr. Doaa Elkady
Lecturer of Prosthodontic department,
Faculty of Oral &Dental Medicine, Cairo University
Dental consideration in
irradiation treated patient

2. Agenda
Introduction to radiotherapy
Effect of radiation on oral and para oral tissues
Factors affecting the rate of damage
Radiotherapy prosthesis
Pre radiotherapy assessment
Prosthetic consideration during complete denture
construction
Implant in irradiated patients

3. Introduction
Cancer patient
surgery radiotherapy Chemotherapy
combination

4. Chemotherapy(cytotoxic effect) Radiotherapy(damaging DNA )

5. Oral manifestations of chemotherapy
Oral
mucositis
xerostomia
Oral
hemorrhage
Infection

6. 3- Oral
hemorrhage
• Thrombocytopenia
• Spontaneous bleeding

7. 4- Infection
Bone marrow
suppression
Lower immunity Leukopenia
Resistant
microorganism
Bacterial , fungal
and viral infection

8. Prevention and treatment prior to
chemotherapy
Dental
treatment
Maintenance
of existing
prosthesis
Fabrication of
new
prosthesis

9. Effect of radiation
on cells
• Somatic changes ( damage to
non reproductive cells)
• Genetic changes (might lead
to defective offspring)

10. Types of radiotherapy
1- External beam radiation (x-ray-
gamma ray radiation It is classified into
A- Orthovoltage(low penetrating power=150-500
Kvp)
B- Super voltage (mega voltage) high penetrating
power(1mev))

11. Types of radiotherapy (continued)
2- Brachy therapy(Radioactive needles , wires. inserted in tissues)
N.B: In brachy
radiotherapy different
types of radioactive
isotopes are used: E.g.
Iodine -125, Radium -
266 and iridium 192,
the latter is the most
common used.
Interstitial
therapy
Surface
mold
therapy
Intra-
cavitary
therapy

12. Effect of radiation on oral
and para oral tissues

14. Immediate effect
Erythema
and
candidiasis
Of mucosa
Angular
cheilitis of
the lip
Tongue
irritation and
ulceration
Conjunctivitis
of the eye
Viscous saliva
and decrease
in its volume

15. Delayed effect
Xerostomia
and trismus
Damaged eye
and cataract
Decalcification
and high caries
index
Atrophy of
mucosa and
tongue
Loss of
appetite
Skin necrosis
Fatty
degeneration of
bone marrow

16. 1- Oral mucositis
• 80% of patients may develop mucositis
• Most commonly involves the anterior
oral cavity (buccal pads, lips, and
tongue).
Mucosal surface
soreness and
ulceration
Sloughing and
thinning
Atrophy of
epithelium

17. Management of
mucositis
• Good dental hygiene :
❑ frequent brushing
❑Avoidance of oral irritants
such as alcohol and tobacco.

18. Coating Agents
• The Multinational Association of
Supportive Care in Cancer (MASCC)
and the International Society of Oral
Oncology (ISOO) updated guidelines
state that benzydamine has a role for
patient receiving moderate dose RT.
• Other agents that have been investigated
include aloe vera gels and honey
products, which may be beneficial for
some patients.

19. Pain Control:
• Topical anesthetics:
• -Lidocaine: ointments, sprays.
• -Benzocaine: sprays, gels.
• 0.5% or 1.0% dyclonine hydrochloride (HCl).
• Analgesics:
• -Benzydamine HCl topical rinse
• -Opioid drugs: oral, intravenous

20. 2- xerostomia (dry mouth)
• Salivary gland hypofunction and xerostomia are
among the most frequent and severe long-term
side effects of radiation therapy to the head and
neck region
• The degree of dysfunction is related to the
radiation dose and volume of glandular tissue in
the radiation field.
• Doses larger than 54 Gy are generally considered
to induce irreversible dysfunction. (Bruno
Correia,2010)
Decrease salivary flow
decrease denture
retention
Decrease protective
mechanism and self
cleansing
Decrease taste
sensation and harden
swallowing
Increase risk of 2ry
infection
Increase caries index
and periodontits

21. Management of
xerostomia
• Preventive measures to reduce oral disease and
associated complications.
• Pharmacologic treatment with salivary stimulants
(sialogogues); and for patients who cannot
tolerate sialogogues,palliative measures to
improve salivary output may be considered, such
as using sugar-free salivary stimulants (e.g.,
chewing gum).
• saliva substitutes that contain xylitol, or that
contain carboxymethylcellulose or
hydroxyethyl cellulose.

22. 3- Candidosis
• Studies have showed that
patients submitted to
radiotherapy have a higher
number of microbiant
species, such as
Lactobacillus ,
Streptococcos aureus and
Candida albicans.
• Clinically, candidosis can be
seen both in its
pseudomembranous and
erythematous forms.

23. Management
• Topical oral antifungal agents
such as nystatin rinse
• Dentures can also be treated
by soaking them overnight in
the antifungal solution.
• - systemic agents should be
used for persistent fungal
infections and in patients with
significant
immunosuppression.
• Eg. Systemic fluconazole

24. 5-Trismus
• Limitations in jaw opening have been reported in
6% to 86% of patients who received radiation to
the temporomandibular joint and/or
masseter/pterygoid muscles
• The loss of function and range of mandibular
motion from radiation therapy appears to be
related to fibrosis in and damage to the muscles of
mastication.

25. Management
❑ Physical treatment
• Aids to improve circulation by
:
⮚Hot fomentation to muscles
of mastication
⮚Massage –increases blood
flow and helps in relaxation of
muscles of mastication.

26. Management
⮚ Exercise to breaks the fibrosis involving
muscles of mastication
⮚ Muscle relaxants – Benzodiazepines
2.5 – 5 mg three times a day may be
indicated in patients with excessive
masticatory muscle spasm

27. facial flex
Therabite
Dynasplint

28. 6. Tooth sensitivity
• -Uncommon complication which occur 4
weeks after starting radiotherapy and
may persist for long time
• -Management
• -Desensitizing tooth paste such as
Sensodyne , topical fluoride gels
• -Dentine bonding agent, such as All
bond, Universal bond-3
7. Alopecia ( Hair Loss)
• -It is a common occurrence, but partial
recovery is possible

29. • 8. Epidermatitis
-This is a common occurrence with
radiation
-Starts with the first two weeks of radiation
and it is seldom long lasting after
completion of therapy
• 9. Dysphagia ( Difficult in
swallowing )
-It is fairly common occurrence, and it may
persist for long time after completion of
therapy

30. 10- Osteo-radio-necrosis(ORN)
According to the most recent literature, ORN of the jaws is defined
as exposed irradiated bone that fails to heal over a period of
3 months without any evidence of persisting or recurrent tumour
the most frequently reported reason of ORN is radiation arteritis.
Radiation arteritis leads to the development of a hypocellular,
hypovascular and hypoxic environment, which results in a
pathological outcome.

31. Prevention of ORN
• Eliminate all sources of dental infection prior to radiation therapy
• Stress on maintenance of oral hygiene
• Allow adequate time for healing of extraction site prior to radiotherapy (14-
21 days)
• Surgical Extraction should be done with adequate alveolectomy to allow
suturing without tension
• If extraction deemed necessary after irradiation it should be done in
conjunction with HBO and antibiotics
• If implants are to be placed in irradiated bone, it should be preceded and
followed by HBO therapy
• Remove metallic superstructure and abutments and cover the implant fixtures
by mucosa if they are in the field of irradiation

32. Treatment:
• Conservative therapy: frequent saline
irrigation and antibiotic medications during
infectious periods
• Marx protocol using HBO in conjunction
with surgery
• advanced stage ORN, is managed surgically
with wide resection and immediate
microvascular reconstruction

33. Role of HBO
• Use as adjunctive modality for treatment of
ORN
• 100% pure 02 at 2.4 ATM pressure for 90
minutes
• Bacteriostatic or bactericidal and increasing
oxygen dependent leukocyte microbial killing
properties
• It relieves , eliminate oro-cutenous fistulas
and achieve osseous union in pathological
fractures
• Increase oxygen tension in tissue, stimulate
collagen synthesis and angiogenesis

34. 11- Soft tissue necrosis
Rare complication present clinically as non-
healing ulcer secondary to soft tissue necrosis
Management: - HBO alone - HBO prior to
surgical closure

35. Factors affecting the rate of damage:
The dose
• The larger
the dose the
higher the
complictions
The mode
• External
radiation is
more
damaging
than brachy
therapy
The rate
• Slow rate,
better
recovery
The field
• The greater
the mass of
radiation the
greater the
damage
Tissue
radiosensitivity
• More
damage in
tissue
replicating its
cells as skin
and intestinal
mucosa
Radical neck
dissection
• Reduce blood
supply and
increase
breakdown
risks

36. Radiotherapy prosthesis:
• Protect tissues that doesn’t require
radiation
• Safer
• Increase accuracy of treatment
• Decrease its side effect
• More comfortable

37. Requirement of radiation prosthesis
prosthesis
comfortable
Light in
weight
Retentive
and stable
Accurate
Suitable
strength
Easy
repaired
and cleaned
Easy
breathing
visualization

38. Beumer classified prosthodontic stents
during radiotherapy according to their use
into:
1- Positioning
stents
2- Sheilding
stents
3- Radiation
positioning
stents
4-
Recontouring
stents

39. 1-
Positioning
stents:
Displace normal tissues away from high
dose radiation
Useful for tongue and floor of the mouth
Prevent deviation of the mandible from
its relationship to maxilla

40. Combination bite opening and tongue positioning stent

41. 2-Lingual
stents:
- Useful in the patients with
carcinoma of the oral tongue that
doesn’t extend into the floor of the
mouth where the dose is boosted
locally
- reduce the dose to the lingual
surface of the mandible
- 1 cm thickness of acrylic resin
reduce the dose by 50%

42. 3- shielding stent:
• Cerrobend alloy ( low-fusing alloy consist
of bisthmus, lead, tin and cadmium)
• Used when treating tumors of buccal
mucosa, lip, skin
• Reduce radiation dose to normal tissues
medial to the tumor

43. A shield for a patient presenting with a squamous carcinoma of buccal
mucosa.
The sheild separate the mandible from the maxilla, this serves to flatten the
buccal mucosa and simplify the dosimetric calculation

44. 4- Radiation positioning stents
Polyethylene tubing is incorporated within the stent
After the stent is positioned it is loaded with radioactive source

45. 4- Recontouring
stents
Simplify dosimetry when
skin lesions associated
with upper and lower
lips
When the beam is
adjusted for midline, the
dosage delivered will be
less at the corners of
the mouth because of
the convex curvature of
lips and face

46. Tissue Bolus Compensators/ Balloon
Bolus Supporting Stents
• help in the treatment of superficial lesions of
the face with irregular contours.
• converts irregular tissue contours into flat
surfaces which are perpendicular to the
central axis of the ionizing beam, thus aids in
the homogenous distribution of the
radiation.
• The most commonly used materials for bolus
are tissue conditioners, water, saline, waxes
and acrylic resin

47. Pre-radiotherapy
Assessment

48. Pre-
radiotherapy
Assessment
- Full medical and dental history
- Diagnosis
- Treatment planning
- Cancer diagnosis should include tumor type,
stage, location within the oral cavity and proximity
or involvement of adjacent structure
- Important treatment factors include the
anticipated radiation dose, field size
( specific areas receiving dose over 60 grays should
considered as high risk for complication)
(NBeech,2014)

49. Pre radiotherapy
management
-
Scaling and fluoride application
Restoration
amalgam may cause back-scatter and subsequent local mucositis,
sharp cusps or restorations is an important issue for
the HNC patient, as these may cause considerable trauma to the
vulnerable irradiated soft tissues. (N Beech,2014)

50. -Impressions should be
taken for study models and
the fabrication of soft
mouth guards or medication
carrying trays
-If the patient wears
dentures, these should be
checked to ensure they are
well-fitting, and not at risk
of causing ulceration

51. Extractions
:
-The extraction of teeth pre-radiotherapy is a
controversial topic because Some studies
have shown that pre-radiotherapy
extractions cause ORN, while other studies
have found that pre-radiotherapy extractions
do not cause ORN

52. The criteria used
by Ben-David et al
are a useful guide
for extractions:
- non-restorable
caries
-caries that extend
to the gum line
-Teeth with -
periodontal
attachment loss
(pocketing >5 mm)
severe erosion or
abrasion
if they are in parts
of the jaws
expected to
receive a high
dose

53. - If extractions are performed, it is important to
allow sufficient healing time before radiotherapy
accepted interval between extractions and
radiotherapy is 14-21 days

54. Prosthetic
consideration
during complete
denture
construction

55. Frequently asked questions
To wear or not to wear the
denture?
Should the dentist use soft liner?
When to make a new prosthesis?
How to deal with apparent bone
necrosis?

56. To wear or nor to wear denture
• Some radiotherapist refused to
permit their patients to wear
dentures and some dentists
refused to fabricate dentures in
particular mandibular dentures
for edentulous patients after the
radiotherapy because of the risk
of ORN.
• beumer et.al, 1976 revealed that the
risk of developing ORN is minimal
particularly if the patient was
edentulous and an experienced
denture user prior to radiotherapy

57. Timing of denture placement
12 to 14 months from irradiation to allow for mucosal healing

58. a- soft liners
Soft liners are
contraindicated to be
used in irradiated
patients because of:
1- high risk of tissue
abrasion.
2- poor adjustability of
silicone.
3- significant increase
in fungal population in
patient with radiation
induced
xerostomia.
4- rapid deterioration
of silicon liners is
observed.

59. Prosthetic management
of irradiated patient:
• Proper relief must be provided in the denture
and the patient should understand the risk of
denture use and be available for close follow
up.
• The risk of developing a soft tissue necrosis
when complete denture are worn appears to be
relatively small and insignificant

60. Prosthodontic procedures
Examination Impressions
Assessment of
vertical
dimension
Occlusal forms
Delivery and
post insertion
care

61. The olive
• Primary ……..alginate
• Secondary….rubber base (special tray with spacer)
• Zinc oxide and plaster impression are contraindicated(irritating and have
drying effect)
• Decrease vertical dimension to decrease force on supporting structure and
increase interocclusal space to facilitate mastication
• Wax wafer method for bite registration
• Smoothen all borders and remove pressure area prior to delivering the patient
• Remounting is essential
• Follow up daily for 2 weeks and every three months thereafter.

62. Implants in irradiated
patients

63. Implant in
irradiated
patients • irradiation per se is not a
contraindication for installation.
• Doses above 55 GY, however, seems
to be critical for implant survival.

64. Patient selection:
Preoperative clinical examination and radiographic evaluation follow standard
procedure.
The patient must be free of any evidence of residual or recurrent tumor prior
to implant placement.
Discontinuation of tobacco use is necessary.
Available bone in the jaw for implant placement is critical at least 15mm of
vertical bone be available(Esser E et.al, 1997).

65. Radiotherapy related risk factors
Radiation dose
Time from
radiotherapy to
implant surgery
Time between
first and second
stage implant
surgery
Soft tissue
condition
Marginal bone
loss

66. Time from radiotherapy to implant
surgery:
• If still not irradiated ,place implants 2 to 3 week prior to
radiation
• Some surgeons prefer inserting implants the day of
tumor removal to benefit osseointegration prior to
radiation
• If patient is on radiation ,wait till the completion of
radiation period at least 6 months (failure rate about
34%) or preferably 1 year
• If the patient already has implant retained bridge and
about to receive radiation, it is preferably to remove
the bridge and replace with healing abutment to
minimize back scatter.

67. Radiation dose
• highest failure rate among
patients was found in those
irradiated with more than 55
GY.

68. Soft tissue condition:
• The most significant problem for irradiated patients
was related to soft tissues
• Cover screw mucosal perforation were observed
over the areas of 17% of implants during the healing
period between stage 1 and stage 2 surgery(Jisander
S et.al1997)