Post radiation complications/ dental courses

INTRODUCTION:
www.indiandentalacademy.com

POST-RADIATION COMPLICATIONS
ACUTE CHRONIC
Oral mucositis
Oral infections
Hyposalivation
Speech and
masticatory problems
Oral infections
Dentofacial abnormality
Trismus and muscle
pain
Taste dysfunction
Osteoradionecrosis
Caries
Ref : Oral Surgery Oral Medicine
Oral Pathology Oral Radiology and
Endodontics, 1999;88(2):122-6

RADIATION MUCOSITIS
 Oral mucositis refers to
erythematous and
ulcerative lesions of the
oral mucosa observed
in patients being treated
with radiation therapy. RADIATION MUCOSITIS

MANAGEMENT OF ORAL MUCOSITIS
“Mucositis Study Group of the
Multinational Association for Supportive
Care in Cancer and the International
Society of Oral Oncology” Guidelines
Pain control
Nutritional
support
Palliation for dry
mouth
Oral
decontamination
Therapeutic
intervention

PAIN
CONTROL
Short term relief
 Saline(0.9%), bicarbonate
rinses, dilute hydrogen peroxide,
topical mouth rinses containing
anesthetics.
 Lidocaine mixed with equal
volumes of diphenhydramine
and a soothing covering agent –
kaolin, pectin, magnesium
hydroxide, aluminium chloride.
MOUTH RINSE CONTAINING
- LIDOCAINE,
DIPHENHYDRAMINE &
COVERING AGENT

 Systemic analgesics
– prescribed by
following the WHO
analgesic “ladder”.
 Analgesics should
be provided on time
contingent basis,
with provisions for
breakthrough pain.
PAIN CONTROL

NUTRITIONAL SUPPORT
 Nutritional intake can be severely compromised
with severe oral mucositis.
 Nutritional intake and weight should be
monitored by a dietician, other professional or
family caregivers.
 A soft and liquid diet is well tolerated.

PALLIATION FOR DRY MOUTH
 Sip water to alleviate mouth dryness.
 Artificial salivary substitutes.
 Chew sugarless chewing gums.
 Rinse with a solution of half a teaspoon of
baking soda in 1 cup of warm water several
times daily.
 Use of cholinergic agents as necessary.www.indiandentalacademy.com

ORAL DECONTAMINATION
Standardized oral care protocol – brushing with
soft toothbrush, flossing, nonmedicated rinses.
Oral lozenges containing polymixin, tobramycin,
amphotericin B – reduce colonization by
Candida and gram-negative bacilli.

Therapeutic intervention
Growth factors
Keratinocyte growth
factor
Anti inflammatory
agent
Benzylamine
hydrochloride rinse
Low-level laser
therapy
Antioxidants
Amifostine –200mg/m3
15 minutes prior to
radiotherapy

SALIVARY GLAND DYSFUNCTION
 Irreversible effects occur at a
total dose of greater than 50
Gy.
 50 to 60% decrease in
salivary flow may occur in 1st
week and after 7 weeks of
therapy diminishes to 20%.
 Recovery is possible until 12
to 18 months and is usually
incomplete.
FISSURED TONGUE
SECONDARY TO
HYPOSALIVATION

MANAGEMENT OF SALIVARY
DYSFUNCTION
 Meticulous oral hygiene.
 Frequent sips of water and a moist diet.
 Sugar free gums, mints, candies to stimulate
salivary flow.
 Mouth wetting agents and salivary substitutes.
 Fluoride : 1.1% solution, NaF, 10 to 15 drops in
custom vinyl tray used every night for 5 minutes
after brushing and flossing. Brushing with neutral
sodium fluoride toothpaste(1.1%).
 Chlorhexidine gluconate 0.12%, hold and rinse
one to two times per day.www.indiandentalacademy.com

MANAGING SALIVARY DYSFUNCTION
Systemic sialagogues:
 Pilocarpine: parasympathomimetic agent, only
drug approved by FDA for use as sialagogue for
radiation induced xerostomia.
 Dose – 5 to 10 mg three times daily for 8 to 12
weeks. Used safely as maintenance therapy.
 Bethanecol – stimulates the parasympathetic
nervous system. Dosage-75 to 200 mg/ day in
divides doses.
 Cevimeline - 30 mg three times dailywww.indiandentalacademy.com

RADIATION INDUCED CARIES
 Lack of production of
saliva.
 Increased acidity.
 Decrease in secretory
immunoglobulin A.
 Loss of buffering
capacity.
 Shift towards cariogenic
flora.
 Reduced remineralizing
potential.
RADIATION CARIES

RADIATION INDUCED CARIES
MANAGEMENT
 Managing hyposalivation.
 Caries resistance:
custom vinyl trays with
neutral sodium fluoride
gel (1.1%) used twice
daily.
 In non compliant patients
- use high potency
fluoride gel and rinses.
CUSTOM TRAYS WITH
FLUORIDE GEL
FLUORIDE GELS AND
RINSES

POST-RADIATION OSTEONECROSIS
Bone in the irradiated field
Hypocellularity
osteoradionecrosis
Reduced capacity of bone
to recover from injury
HypoxiaHypovascularity

MANAGEMENT OF POST RADIATION
OSTEONECROSIS
 Discontinue use of dental appliances.
 Maintain nutritional status.
 Strict abstinence from tobacco and alcohol.
 Comprehensive management of chronic
nonprogressive osteonecrosis : removal of bony
sequestrae, antibacterial rinses (chlorhexidine
gluconate), topical antibiotics (tetracyclin rinse)
or systemic antibiotics (penicillin /
metronidazole/clindamycin)

MANAGEMENT OF POST-RADIATION
OSTEONECROSIS
 Hyperbaric oxygen therapy
(HBO) : active, progressive
osteonecrosis- 100% oxygen
and 2 to 2.5 atmospheric
pressure for 20 to 30 dives
and 10 dives post surgical.
HBO THERAPY

MANAGEMENT OF POST-RADIATION
OSTEONECROSIS
Hyperbaric Oxygen Therapy
Increases
oxygenation
of tissues
Promotes
osteoblast
activity
Promotes
fibroblast
activity
Increases
angiogenesis

TASTE AND SMELL DYSFUNCTION
 Taste loss may begin with radiation doses of 20
Gy, and with 30 Gy all taste qualities are
affected.
 Alterations of smell occur commonly in the
course of treatment of nasopharyngeal and
maxillary antrum carcinomas.
 Zinc sulfate, 220 mg two times per day, help with
the recovery of taste dysfunction.
 Use of saline nasal sprays are sometimes
helpful.

ORAL INFECTIONS
BACTERIAL INFECTIONS
Infections related to caries
and non vital teeth
Long term broad spectrum
antibiotics, incision and
drainage, surgical
debridement, HBO therapy.
Bacteremia
Empiric antibiotic-
vancomycin, culture and
susceptibility.
Periodontal infections
and pericoronitis
Scaling and curettage,
topical and systemic
antibiotic therapy- penicillin,
clindamycin, metronidazole.
Parotitis
Empiric antibiotic-amoxicillin or
clindamycin, culture and
susceptibility test, warm
compressors, adequate
rehydration, nutritional support.www.indiandentalacademy.com

ORAL INFECTIONS
 Oropharyngeal candidiasis
is the most common fungal
infection in cancer patients.
 Deep fungal infections in
patients with non healing
ulcerated lesions, can be
caused by Aspergillus,
Zygomyces, and endemic
fungi, such as Histoplasma
capsulatum.
FUNGAL INFECTION
CANDIDIAL INFECTION

ORAL INFECTIONS
TOPICAL MANAGEMENT
“Infectious Diseases Society of
America” Guidelines
Initial episode-swish and
spit protocol-
Clotrimazole troches(10
mg), Nystatin oral
suspension(100,000U/ml),
qid for 7-14 days
Refractory infection-
swish and swallow
protocol-
Amphotericin B(100mg/ml)
- 1 ml, qid, 7-14 days
Dentures disinfected by
soaking in Chlorhexidine
gluconate(0.12%) rinse, Sodium
hypochlorite(1:10),Glutaraldehyde
(2%), 20-30 minutes dailywww.indiandentalacademy.com

ORAL INFECTIONS
SYSTEMIC MANAGEMENT
 First generation trizoles, fluconazole or
itraconazole, 100-200 mg/day for 7-14 days.
 Voriconazole and posaconazole, newer trizoles,
may be effective against resistant strains.
 For refractory cases - systemic echinocandins
(caspofungin, micafungin)-50 to 70 mg daily
and amphotericin B formulations
(deoxycholate)-50mg/kg/day.www.indiandentalacademy.com

TRISMUS AND MUSCLE PAIN
 Radiotherapy may
induce fibrosis and
atrophy in the
masticatory muscles
or TMJ as a late
radiation effect,
typically developing
3 to 6 months after
radiotherapy.
TRISMUS

TRISMUS AND MUSCLE PAIN
 Mandibular stretching exercises and use of
dynamic bite openers, rubber plugs, tongue
blades stacked together.
 Pentoxifyllin – a methylxanthine derivative, has
immunomodulatory properties and down
regulates certain cytokines, reducing radiation
induced fibrosis.
Goal is to restore range of
motion and to alleviate
pain and dysfunction.

CONCLUSION
 The management of acute and chronic
complications during and after radiotherapy
poses many challenges to the dental
practitioner.
 The dental professionals should be able to
identify these complications, providing
preventive and supportive care, including
education and symptom management and
closely monitor each patient’s level of
distress, ability to cope and response to
treatment .

Thank
You

Post radiation complications/ dental courses

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