For the usage of Dental Professionals

4. 4
INTRODUCTION
About The Handbook
This handbook serves as a quick reference for dental
officers in Special Needs Dentistry Department, Hospi-
tal Kajang in managing patients with certain conditions
which require special and precise management such
as those who have undergone head and neck cancer
and requiring radiation therapy and chemotherapy, on
anti-resorptive medication therapy and steroid supple-
ment requirement. It may not outline everything in de-
tails but the references are listed at the last page of the
book if more information is required.
It is a pleasure to provide the officers with this guidance
to prevent confusion and post-operative complications.
I hope that it will be helpful and useful.

5. 5
Dental assessment prior to radiation therapy
Aim :
To prevent
osteoradionecrosis

6. 6
1. Patient for pre-assessment should be seen at least 1 month
prior to commencement of radiotherapy. Call and inform
the oncologist if more time is required.
2. Any existing oral diseases or issues and potential risks
of oral diseases should be identified1,2
:
a. Take appropriate radiographs (OPG or PA) to identify
any infection or pathology
b. Any restorative or periodontal treatment required must
be arranged with the aim to minimize the periodontal
infections
c. Teeth with poor prognosis need to be extracted (molar
tooth with PA lesion, periodontal pocket ≥ 5 mm,
furcation involvement, total radiation dose > 60 gy to the
affected area)8,9
d. Poorly fitting denture should be adjusted accordingly to
prevent trauma to the mucosal structure

7. 7
3. Any dental infections should be
managed before the patient is
announced as dentally/orally fit
for head and neck radiotherapy
4. Patient and carer should be
prepared and informed about
the possible side effects of the
therapy

8. 8
5. Individual preventive
plan must be develope
which includes1
:
a. Healthy diet and reduced
of sugary snacks and drinks
b. Maintaining good oral
hygiene care at home
(specify the frequency
of toothbrushing, types
of toothbrush and
toothpaste, mouhtwash)
c. Prescribing fluoridate
toothpaste and
flouridated alcohol free
mouhtwash
d. Regular dental check
up at dental clinic every
3 months following the
completion of radiotherapy
6. If the extractions need to be
done:
a. All extractions should
be done 3-6 weeks prior to
initiation of radiation
therapy to allow
adequate healing or at
least completed 10 days
prior the start of
radiotherapy4
b. Perform atraumatic
dental extraction
wherever possible and
eliminate sharp bony
projections
c. Do not overstretch the
mucosa and achieve
primary closure
d. Alarm the oncology team
that an extraction was
performed (if radiotherapy
is scheduled in the next
1 month and state the date
of last extraction)

9. 9
Dental treatment during radiation therapy
Aim :
To prevent severe
oral mucositis and
secondary infections
To control pain and
support ingestion

10. 10
Implement high
standard of oral hy-
giene care includ-
ing denture hygiene
(brushing with
extra soft tooth-
brush, flossing
and mouthrinsing
with alcohol-free
mouthwash)
S y m p t o m a t i c
treatment ap-
proach (look for
any signs such as
mucositis, viral
and fungal infec-
tions and xeros-
tomia), treat ac-
cordingly
Appropriate
dietary
advice
1
2
3
4
5
Avoid any
elective
dental
treatment
Iftoothbrush-
ing is not pos-
sible due to
mucositis, oral
cleaning with
sponge, oral
cleanser stick
(toothette) can
be done with
alcohol free
chlorhexidine
mouthwash

11. 11
Dental treatment after radiation therapy
Aim :
To prevent and treat
dental caries
To prevent
osteoradionecrosis

12. 12
60 Gy
1. Identify patients who are high risk to
devel op osteoradionecrosis such as:
• Total radiation dose is more than 60 Gy4,6
• Large fraction dose, high number of
fractions1
• Local trauma due to tooth extraction,
uncontrolled periodontal disease and
poorly fitting dentures1
• Immunodeficient1
• Malnourished1
2. Due to the risk of osteoradionecrsis, avoid
invasive surgical procedures, involving
exposure of irradiated bone for at
least 6-12 months after radiatiotreatment
especially for high risk patients.

13. 13
60 Gy
3. Encourage soft diet, high maintenance
of oral hygiene, timely dental review
and prompt treatment to dental
trauma
4. If tooth extraction is unavoidable,
exercise extreme caution while
extracting the tooth. Conservative
surgical technique and antibiotic
coverage should be given to assure
complete healing.
Most spontaneous presentations of ORN occurred
between 6 months and 2 years after RT, whereas the
risk of developing trauma-induced ORN lasts
indefinitely. This observation explains the occurrence
of ORN even 10 years after RT. 90% or more of ORN
cases occur within the first 3 years after RT. Others
have found that 70%-80% ORN developed within the
first 3 years.Shorter mean and median times to onset
of ORN after RT of 6 months and 13 months,
respectively, also have been reported6.

14. 14
Extraction protocol
Antibiotic regime: Mouthwash8
:
In urgent cases where dental ex-
traction has to be performed
on that particular day:
Cap Amoxycillin 2 g STAT / Cap Clinda-
mycin 600mg STAT prior to procedure
and continue taking 500 mg Amoxycil-
lin, tds for 7 days after the extraction
Antibacterial mouthwashes with 10 ml of
undiluted chlorhexidine gluconate 0.2%
solution for 1 min every 12th hourly start-
ing from 10 days before the extraction
Start antibiotic therapy Cap.Amoxycillin
500 mg tds/ Cap.Clindamycin 300mg tds
7 days prior to dental extraction and con-
tinue 7 days after extractions
In scheduled dental extractions8
:
Antibiotic prophylaxis may be given if:
Patient is high risk to develop ORN
Poor oral hygiene
Extensive/ invasive oral surgery required
Tooth to be extracted is within the radia-
tion field

15. 15
Extraction protocol
Surgical protocol7
:
Administration of local anesthesia (e.g lidocaine 2% sol, adr
1:200,000-xylocaine)/prilocaine 3% sol, octapressin –Citanest 3%,
octapressin 0.03 I.U per ml)
Atraumatic extraction
Debride the socket gently to remove loose fragments and smooth-
en the socket wall with bone file to remove sharp bony edges.
Irrigate the socket with sterile normal saline
Suture socket with vicryl 4-0
May consider other options such as root
canal treatment or
decoranation of the tooth in high
radiation area

16. 16
Extraction protocol
Follow up
appointments:
1
2
3
1 week postoperatively
Then once a month for 6
months
Then every 3 month for
2 years

17. 17
OSTEORADIONECROSIS1
Stage 0
Stage I
Stage II
Stage III
Mucosal defects only;
bone exposed
Radiological evidence
of necrotic bone,
dento-alveolar only
Positive radiographic findings
above ID canal with denuded
bone intraorally
Clinically exposed radionecrotic bone,
verified by imaging techniques, along
with skin fistulas and infection with ad-
dition of potential or actual pathological
fracture1

18. 18
Consider the use of pentoxifylline and tocopherol when ORN is present
“The Antioxidant agent, pentoxi-
fylline (PTX), facilitates microcir-
culation, and inhibits the inflam-
matory mechanisms, promotes
fibroblast proliferation and the
formation of extracellular matrix.
Tocopherol (vitamin E) protects
the cell membrane against perox-
idation. A synergic effect has been
observed between PTX and to-
copherol in the treatment of ORN.
These are accessible, well-toler-
ated and safe drugs at a suggest-
ed daily dosage of: PTX dose of
800mg/day and vitamin E 1000
IU/day. The evidence base for us-
ing these drugs is developing, and
there is a lack of randomised con-
trolled clinical trials supporting the
use of these drugs.”1
“Wide spectrum high dose antibi-
otics (Augmentin = amoxicillin +
clavulanic acid) can be prescribed
if symptomatic along with local-
ized debridement of sequestra and
other debris from the intra oral de-
fect.”1
If any surgery required, please
discuss with the OMFS surgeon.

19. 19
1. The Royal College of Surgeons of England / The British Society for Disability and Oral Health. 2018. Clinical
Guidelines on The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and / or
Bone Marrow Transplantation.
2. Scottish Dental Clinical Effectiveness Programme, 2017. Dental Clinical Guidance on Oral Health Management of Patients at
Risk of Medication-related Osteonecrosis of the Jaw.
3. Kawashitaa,Y., Soutomea, S., Umeda, M., Saitoc, T. 2020. Oral management strategies for radiotherapy of head and neck
cancer, Japanese Dental Science Review, 56, 62-67.
4. Clayman, L. 1997. Clinical controversies in oral and maxillofacial surgery: Part two. Management of dental extractions in
irradiated jaws: a protocol without hyperbaric oxygen. J Oral Maxillofacial Surg, 55, 275-281. (5).
5. McCaul, L. 2012. Oral and dental management for head and neck cancer patients treated by chemotherapy and
radiotherapy. Dent Update, 39, 135-8, 140. (5).
References 1

20. 20
6. Nabil, S., and Samman, N. 2011. Incidence and prevention of osteoradionecrosis after dental extraction in irradiated patients:
a systematic review. Int J Oral Maxillofac Surg, 40, 229-43. (3a).
7. Al-Bazie, S. A., Bahatheq, M., Al-Ghazi, M., Al-Rajhi, N., & Ramalingam, S. 2016. Antibiotic protocol for the prevention of
osteoradionecrosis following dental extractions in irradiated head and neck cancer patients: A 10 years prospective study.
Journal of cancer research and therapeutics, 12(2), 565.
8 Lee IJ, Koom WS, Lee CG, Kim YB, Yoo SW, Keum KC, et al. 2009. Risk factors and dose-effect relationship for mandibular
osteo radionecrosis in oral and oropharyngeal cancer patients. Int J Radiat Oncol Biol Phys, 75:1084–91.
9. Gomez DR, Estilo CL, Wolden SL, Zelefsky MJ, Kraus DH, Wong RJ, et al. 2011. Correlation of osteoradionecrosis and
dental events with dosimetric parameters in intensity-modulated radiation therapy for head-and-neck cancer. Int J Radiat
Oncol Biol Phys, 81:e207–213.
10. National Comprehensive Cancer Network. Principles of Dental Evaluation and Management (DENT-A). NCCN Guidelines
Version 2019 Head and Neck Cancers. Available from: https://www.nccn.org/professionals/physiciangls/
pdf/head-and-neck.pdf. [Accessed 13 January 2020].
References 1

21. 21
Aim :
To prevent Medication
Related Osteonecrosis
of the Jaw (MRONJ)
Dental extraction protocol for patients on
anti-resorptive medications

22. 22
Low Risk Oral Health Management Extraction Protocol
Patients being treated for osteoporosis or
other non-malignant diseases of bone (e.g.
Paget’s disease) with oral bisphosphonates
for less than 5 years who are not
concurrently
being treated with systemic glucocorticoids.
1. Routine dental treatment can be carried
out as normal
2. Continue personalized preventive care
1. Discuss the benefit and risks of the
associated treatment
2. Gain informed and valid consent
3. Consider drug holiday (2-3 month prior
to extraction and 3 months following the
tooth extraction) only after the
discussion with the treating physician
and the medical condition permits
(Damn and Jones, 2013) OR
4. Postpone non-urgent treatment until the
month of the next dose of the drug
(especially for IV or subcutaneous
denosumab-6 monthly)
5. Start antibiotic therapy Cap.Amoxycillin
500 mg tds/ Cap.Clindamycin 300mg
tds 7 days prior to dental extraction and
continue 7 days after extractions
6. Proceed with extraction as indicated
(Refer slides on extraction protocol
details)
7. Review healing (Refer to the review
regime)
Patients being treated for osteoporosis or
other non-malignant diseases of bone with
quarterly or yearly infusions of intravenous
bisphosphonates for less than 5 years who
are not concurrently being treated with
systemic glucocorticoids.
Patients being treated for osteoporosis or
other non-malignant diseases of bone with
denosumab who are not being treated with
systemic glucocorticoids.
Risk Assessment and Management Protocol2,8

23. 23
High Risk Oral Health Management Extraction Protocol
Patients being treated for osteoporosis or
other non-malignant diseases of bone (e.g.
Paget’s disease) with oral bisphosphonates
or quarterly or yearly infusions of
intravenous
bisphosphonates for more than 5 years.
1. Routine dental treatment can be carried
out as normal
2. Consider all alternative dental treatment
prior to deciding on dental extraction
e.g retaining the root
3. Continue personalized preventive care
1. Discuss the benefit and risks of the
associated treatment
2. Gain informed and valid consent
3. Consider drug holiday (2-3 month prior
to extraction and 3 months following the
tooth extraction) only after the
discussion with the treating physician
and the medical condition permits
(Damn and Jones, 2013) OR
4. Postpone non-urgent treatment until the
month of the next dose of the drug
(especially for IV or subcutaneous
denosumab-6 monthly)
5. Start antibiotic therapy Cap.Amoxycillin
500 mg tds/ Cap.Clindamycin 300mg
tds 7 days prior to dental extraction and
continue 7 days after extractions
6. Proceed with extraction as indicated
(Refer slides on extraction protocol
details)
7. Review healing (Refer to the review
regime)
Patients being treated for osteoporosis or
other non-malignant diseases of bone with
bisphosphonates or denosumab for any
length of time who are being concurrently
treated with systemic glucocorticoids.
Patients being treated with anti-resorptive or
anti-angiogenic drugs (or both) as part of the
management of cancer
Patients with a previous diagnosis of
MRONJ.
Risk Assessment and Management Protocol2,8

24. 24
Extraction protocol
Cap Amoxycillin 2 g STAT / Cap Clinda-
mycin 600mg STAT prior to procedure
and continue taking 500 mgAmoxycillin,
tds for 7 days after the extraction
Start antibiotic therapy Cap.Amoxycillin
500 mg tds/ Cap.Clindamycin 300mg
tds 7 days prior to dental extraction and
continue 7 days after extractions
Antibiotic regime: Mouthwash6
:
In urgent cases where dental ex-
traction has to be performed
on that particular day:
Antibacterial mouthwashes with 10 ml of
undiluted chlorhexidine gluconate 0.2%
solution for 1 min every 12th hourly start-
ing from 10 days before the extraction
In scheduled dental extractions8
:

25. 25
Extraction protocol
One tooth at a time or sextant by sextant approach
Administration of local anesthesia (e.g lidocaine 2% sol, adr 1:200,000-xylo-
caine)/prilocaine 3% sol, octapressin –Citanest 3%, octapressin 0.03 I.U per
ml)
Atraumatic extraction
Debride the socket gently to remove loose fragments and smoothen the
socket wall with bone file to remove sharp bony edges.
Irrigate the socket with sterile normal saline
Place the haemostatic agent/ plasma rich growth factor (PRGF)
Suture socket with vicryl 4-0 by primary or secondary closure

26. 26
Extraction protocol
Follow up
appointments:
1
2
3
1 week postoperatively
Then once a month for 6
months
Then every 3 month for 2
yearsIf the extraction socket is
not healed in 8 weeks,
suspect that the
patient may have
MRONJ

27. 27
Treatment approach for medication related
osteonecrosis of the jaw (mronj)6

28. 28
MRONJ Staging and Treatment Approach6
Exposed and
necrotic bone
or fistulas that
probes to bone
in patients who
are asympto-
matic and have
no evidence of
infection
Antibacterial
mouthwash,
mobile bony
sequestra
should be re-
moved so as
to facilitate
soft tissue
healing
No treatment
required
At risk
1
0
No clinical evi-
dence of necrotic
bone but nonspe-
cific clinical find-
ings, radiographic
changes, and
symptoms noted
No apparent
necrotic bone
in patients who
have been treat-
ed with oral or
intravenous
bisphosphonates
Systemic antibiotic (500 mg
Amoxycillin tds 1/52)

29. 29
Antibacterial
mouthwash, surgi-
cal debridement/
resection for
longer term palli-
ation of infection
and pain, symp-
tomatic patients
may require resec-
tion and immedi-
ate reconstruction
with a plate or an
obturator, in-
cluding the usage
of vascularized
bone7, sympto-
matic teeth within
exposed necrotic
bone should be
extracted
Antibacterial
mouthwash,
debridement to
relieve soft tissue
irritation and for
infection control,
mobile bony
sequestra should
be removed so as
to facilitate soft
tissue healing,
systemic anti-
biotic (500 mg
Amoxycillin tds
1/52)
Exposed and necrot-
ic bone or fistulas that
probes to bone associ-
ated with infection as
evidenced by pain and
erythema in the region
of exposed bone with or
without purulent drainage
Exposed and necrotic
bone or a fistula that
probes to bone in pa-
tients with pain, infec-
tion, and ≥ 1 of the follow-
ing: exposed and necrotic
bone extending beyond
the region of alveolar
bone (i.e. inferior bor-
der and ramus in man-
dible, maxillary sinus,
and zygoma in maxilla)
resulting in pathologic
fracture, extraoral fis-
tula, oral antral, or oral
nasal communication,
or osteolysis extending
to inferior border of the
mandible or sinus floor
3
2
MRONJ Staging and Treatment Approach6

30. 30
1. The Royal College of Surgeons of England / The British Society for Disability and Oral Health. 2018. Clinical
Guidelines on The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and / or
Bone Marrow Transplantation.
2. Scottish Dental Clinical Effectiveness Programme. 2017. Dental Clinical Guidance on Oral Health Management of
Patients at Risk of Medication-related Osteonecrosis of the Jaw.
3. Damm D.D. and Jones D.M. 2013. Bisphosphonate-related osteonecrosis of the jaws: A potential alternative to
drug holidays. General Dentistry; 61:33-38.
4. Mozzati M., Arata V. and Gallesio G. 2013. Tooth extraction in osteoporotic patients taking oral bisphosphonate.
Osteoporosis International, 24:1707-1712.
5. Scoletta M., Arata V., Arduino P.G., et al. 2013. Tooth extractions in intravenous bisphosphonate-treated
patients: A refined protocol. Journal of Oral and Maxillofacial Surgery, 71:994-999.
References 2

31. 31
6. Ruggiero SL, Dodson TB, Fantasia J, et al. 2014. American Association of Oral and Maxillofacial Surgeons.
Medication-related osteonecrosis of the jaw. Position paper. Journal of Oral and Maxillofacial Surgery,
72:1938-1956.
7. Seth R., Futran N.D., Alam D.S. and Knott, P.D. 2010Outcomes of vascularized bone graft reconstruction of the
mandible in bisphosphonate-related osteonecrosis of the jaws. Laryngoscope, 120:2165-2171.
8. Smith S.J., AlQranei M., Adel S., Almas A&K. 2018. Tooth Extraction Protocols for Patients on Bisphosphonate
Therapy: An Update, Journal of the International Academy of Periodontology, 20/1: 38–4
References 2

32. 32
Required or Not
required?
Element Title
What is the dose?
Criteria
StEroid cover for dental treatment

33. 33
Currently on prednisolone ≤ 10mg/day
for ≥ 3 weeks : no supplement with good
LA and post op pain control
Currently on prednisolone > 10mg /day
> 1 week: no supplement with good LA
and post op pain control OR double the
dose on the day of procedure depending
on patient’s anxiety level (may confirm
with an increase in BP/HR/PR)
Past history of using steroid and > 3
weeks but stop taking ≤ 3 months: treat
as patient is on steroid based on the
previous dose
Past history of using steroid and > 3
weeks but stop taking > 3 months : no
supplement required
Minor Surgery under GA:
100 mg hydrocortisone intramuscularly
should be administered pre-operatively
and the usual glucocorticoid medica-
tions maintained.
Major surgery under GA:
100 mg hydrocortisone delivered as a
bolus pre-operatively followed by 50
mg 8-hourly for 48 hours post opera-
tively
GENERAL ANAESTHESIA
Every day, 24 to 30 mg of cortisol (equiv-
alent
to 5–7.5 mg prednisolone) is released
in a rhythmic pulsatile fashion. Under
stress this may increase to 300 mg (60 mg
prednisolone equivalent) per day.
Steroid cover: required or not?1,5

34. 34
Discuss the dental procedure and steroid cover with the patient in
advance. Most patients with Addison's disease will be knowledgea-
ble about their steroid requirements.
Provide written advice on any supplementation and top-up doses
of hydrocortisone required.
Ensure the patient has sufficient doses of hydrocortisone (or other
glucocorticoid) to take prior to the dental procedure and after the
procedure, if required.
Ensure that the patient knows what to do if symptoms of adrenal
insufficiency occur after the procedure.
Agree with the patient whether they will bring their own emergency
hydrocortisone kit or if the surgery needs to obtain one.
Steroid supplementation for patient with
primary adrenal disease6
General Rules:

35. 35
Steroid supplementation for patient with
primary adrenal disease6
Take his/her usual morning dose of
steroid on the day of the procedure
and continue taking the usual daily
dose(s) after the procedure
A
B
C
A double dose of hydrocortisone tak-
en one hour prior to surgery, up to a
maximum dose of hydrocortisone 20
mg (or equivalent glucocorticoid). To
continue taking a double dose for a
full 24 hours after the procedure, be-
fore returning to the usual dose.
Intramuscular or intravenous hydro-
cortisone pre-operatively. After sur-
gery, the usual oral dose of steroid
should be doubled for the next 24
hours.
A
B
C
Major dental surgical
procedure, eg mul-
tiple tooth extrac-
tion under general
anaesthetic
Minor oral surgery,
eg tooth extraction.
Minor dental proce-
dure, eg scaling and
polishing, replace-
ment of a filling, root
canal treatment

36. 36
Example of steroid calculation6
The patient normally takes 10 mg
hydrocortisone twice daily (at 7.30 am
and 5 pm) and the dental appointment is
at 10 am:
• Take 10 mg at 7.30 am;
• Take 20 mg at 9 am (one hour before
procedure);
• Take 20 mg at 5 pm;
• Take 20 mg at 7.30 am the morning after
the procedure;
• Resume normal dosing at 5 pm (ie take
10 mg as usual).
The patient takes 15 mg hydrocorti-
sone at 8 am and 5 mg at 6 pm and
the dental
appointment is at 2.30 pm:
• Take 15 mg at 8 am;
• Take 10 mg at 1.30 pm (one hour
before
procedure);
• Take 10mg at6pm;
• Take 20 mg at 8 am the morning
after the procedure;
• Resume normal dosing at 6 pm
(ie take 5mg as usual).
Case 1
Case 2

37. 37
1. Little, J.W.; Falace, D.A., Miller, C.S., Rhodus, N.L. 2002. Adrenal Insufficiency. In: Dental Management of the
Medically Compromised Patient. 6th ed. St.Louis: Mosby.
2. Oxford Handbook of Anaesthesia. Second Edition 2006.
3. Nicholson G. 1998. Perioperative steroid supplementation. Anaesthesia, 53:1091-104
4. Yong S.L., 2012. Supplemental perioperative steroids for surgical patients with adrenal insufficiency (review).
The Cochrane Database of Systematic Reviews, Issue 12.
5. Gibson, N., Ferguson, J.W. 2004. Steroid cover for dental patients on long-term steroid medication: proposed
clinical guidelines based upon a critical review of the literature. British Dental Journal, Volume 197 No. 11 December 11.
6. Henderson, S. 2014. What Steroid Supplementation is Required for a Patient with Primary Adrenal Insufficiency
Undergoing a Dental Procedure?, Dent Update, 41: 342-344
References 3

38. 38
DR SITI ZALEHA HAMZAH
HEAD OF DEPARTMENT & SPECIALIST IN SPECIAL NEEDS
DENTSITRY.
DR ARUNA A/P RAMASAMY
CLINICAL SPECIALIST IN SPECIAL NEEDS DENTISTRY.
DR REENARAJ KAUR SANDHU GURNAM
SINGH
DENTAL OFFICER
DR FARAH HIDAYAH MOHD FAZLI
DENTAL OFFICER
Acknowledgement
DR SITI ZALEHA HAMZAH
HEAD OF DEPARTMENT & SPECIALIST IN SPECIAL NEEDS DENTISTRY.
DR ARUNADEVI A/P RAMASAMY
CLINICAL SPECIALIST IN SPECIAL NEEDS DENTISTRY.
DR REENARAJ KAUR SANDHU GURNAM SINGH
DENTAL OFFICER.
DR FARAH HIDAYAH MOHD FAZLI
DENTAL OFFICER.