The document summarizes guidelines for oral assessment and management before, during, and after head and neck radiation therapy (R/T). It recommends a complete dental examination before R/T to identify issues and extractions to reduce complications. During R/T, daily oral hygiene and topical fluoride are emphasized to prevent side effects like mucositis, infection, and xerostomia. Long-term, frequent follow-up is needed due to risks like osteoradionecrosis and new malignant disease. The goal is to minimize oral morbidity at all treatment stages.

1. Pre R/T Dental Management
Presenter: R1 鄭瑋之
Instructor: VS 陳靜容醫師
Date: 2012/3/16

2. Oral Assessment before R/T
• Acute effects of RT: mucositis, altered salivary
gland function and risk of mucosal infection.
• Long-term effects of RT: hypovascularity,
hypocellularity and hypoxia of the tissues, damage
to the salivary glands and increased collagen
synthesis resulting in fibrosis. The affected bone
and soft tissue have a reduced capacity to remodel.
• A consultation with a dental teamshould be
completed before the start of therapy.

3. Oral Assessment before R/T
1. A complete dental examination to identify
preexisting problems.
2. Prior to treatment, potentially complicating
diseases should be corrected.
3. Patient adherence to hygiene protocols are
critical.

4. Strategies
Before R/T
Medical history Prior cancer history, risk factors
Definitive diagnosis Tumour size and type
Dental knowledge Past and current dental care
Oral hygiene Current practices
Complete dental examination Mucosa, dentition, periodontium, TMJ
Radiographic examination Panoramic, selected periapical, bitewing
Resting (> 0.1 mL/minute),
Whole salivary flow rates
stimulated (> 1.0 mL/minute)
Pulp tests, specific cultures (fungal, viral,
Adjunctive tests as indicated
bacterial)
Prognosis (cure or palliation)
Proposed radiation therapy Timing, dose, fields

5. Oral Assessment before R/T
• All teeth, but especially those located within the
radiation fields, should be closely evaluated.
• Only 11.2% of patients required no dental
treatment before RT.
• The criteria for extractions before R/T are not
universally accepted and are subject to clinical
judgement.

6. Criteria for pre R/T extractions
• Teeth in the high-dose radiation field and
– Caries (nonrestorable)
– Active periapical disease (symptomatic teeth)
– Moderate to severe periodontal disease
– Lack of opposing teeth, compromised hygiene
– Partial impactions or incomplete eruption
– Extensive periapical lesions (if not chronic or well
localized
• A more aggressive dental management strategy
should be considered for patients with limited
previous dental care, poor oral hygiene and past
dental or periodontal disease

7. Guidelines for extractions
• At least 2 weeks, ideally 3 weeks, before R/T.
• Trim bone at wound margins to eliminate sharp
edges.
• Primary closure should be done.
• Intra alveolar hemostatic packing agents should be
avoided that can serve as a nidus of microbeal
growth.
• If the platelets count is < 50000/mm3 than
transfusion is mandatory.
• Delay the extraction if the WBC < 2000/mm3 or
absolute neutrophil is < 1000/mm3. Prophylatic
antibiotics .

8. During R/T
• Monitoring of the oral cavity
• Systematically applied oral hygiene protocols may
reduce the incidence, severity and duration of oral
complications.
• Frequent brushing with a soft-bristled toothbrush
and fluoride toothpaste or gel to help prevent
plaque accumulation and demineralization or
caries of the teeth.

9. Strategies
During R/T
Brushing 2 to 4 times daily with
Maintenance of good oral hygiene
soft-bristled brush; flossing daily
Custom trays, brush-on
Daily topical fluoride
prescription-strength fluoride
Frequent saline rinses
Lip moisturizer (non-petroleum based)
Passive jaw-opening exercises to
reduce trismus

10. Side Effects of R/T
• Directly affects the salivary glands, the mucosal
membranes, the jaw muscles and bone.
1. Dry mouth (xerostomia): loss of saliva  periodontal
disease, rampant caries, and oral fungal and bacterial
infections.
2. Oral Infection (Candida)
3. Oral Mucositis: by the 3rd week of treatment
4. Fibrosis around the mastication m.  trismus
5. Bone: blood flow↓, loss of osteocytes  limited
remodelling of bone and limited healing potential

11. If >40Gy , permanent
Xerostomia dysfunction of the salivary
glands should be expected.
• Sialagogues
residual function
Sjogren’s disease
• No optimal substitute for saliva: without
rheologic and antimicrobial factors
• Sugarless gum or lozenges, ice cubes or ice
water, eating foods high in ascorbic acid, malic
acid or citric acid, but not recommended in
dentate patients

12. Xerostomia
• For the prevention of rampant caries 
1. Apply 1.1% neutral sodium fluoride gel daily
(for at least 5 minutes) with a custom fitted
vinyl tray.
2. Started on the first day of R/T and
continued daily as long as salivary flow rates
are low.
3. High-potency fluoride brush-on gels and
dentifrices in those who are unable or
unwilling to comply with the use of fluoride
trays.

13. Oral Infection
• A fungal, bacterial or viral culture
• Candida ↑ during R/T (pseudomembranous, ,
chronic hyperplastic, chronic cheilitis)
contraindications
liver toxicity
unpleasant flavour, may cause nausea and vomiting, high sucrose content.
antifungal, antibacterial and antiplaque

14. Oral Infection
• If CHX is used, it is important to note that
nystatin and CHX should not be used
concurrently, because chlorhexidine binds to
nystatin, rendering both ineffective.
• CHX should be used at least 30 minutes
before or after the use of any other topical
agents with which it may bind.
• Viral infections, such as Herpes simplex 1 
acyclovir or penciclovir (newer, with
increased tissue penetration)

15. Mucositis
• Combinations of rinses: interfere  dilution
• Isotonic saline/sodium bicarbonate
• Prophylactic rinses with CHX  Candida
counts↓ but has no effect on mucositis.
• Cheapest and easiest: a teaspoon (10 mL) of salt
+ a teaspoon (10 mL) of baking soda (sodium
bicarbonate) in 8 ounces (250 mL) of water.
• Oral rinses should be discontinued because of
their drying and irritating effects.
• The discomfort can be reduced with coating
agents, topical anesthetics and analgesics.

16. Mucositis •occurs 12- 17 days after the
initiation of therapy
contraindications
Risk of aspiration↑
Systemic absorption  cardiac effects
Lack of saliva and damaged taste buds 
Alter the sensation of taste (transient phenomenon) 
compensate by increasing intake of sugar

17. After R/T
• After the completion of R/T, acute oral
complications usually begin to resolve.
• Oral exercises should be continued to
reduce/prevent trismus.
• Additional dietary adaptations
• Long-term management and close follow-up of
patients after radiation therapy is mandatory.
• Excellent time to resolve any deferred dental care.

18. Strategies
After R/T
Complete dental work that was
deferred during radiotherapy
Maintain integrity of teeth Especially those in radiation fields
Check for oral hygiene, xerostomia,
decalcification, decay, ORN,
Frequent follow-up appointments
metastatic disease, recurrent disease,
new malignant disease

19. Osteoradionecrosis
• Irreversible, progressive devitalization of irradiated
bone
• Most in the mandible, where vascularization is poor
and bone density is high.
• Symptoms: pain, orofacial fistulas, exposed necrotic
bone, pathologic fracture and suppuration
• One-third of cases occur spontaneously.
• The majority result from extraction of teeth.
• Incidence: dentate = edentulous*2
• Poor oral hygiene and continued use of alcohol and
tobacco may also lead to rapid onset of ORN.
• Hyperbaric oxygen therapy in conjunction with
surgery has better success rates.

20. Conclusion
• The complications of radiotherapy must be
considered thoroughly so that every effort is
undertaken to minimize the oral morbidity of
these patients before, during and after cancer
treatment and throughout the patient’s
lifetime.

21. Referrence
1. Pamela J. Hancock, BSc, DMD, Joel B.
Epstein, DMD, MSD, FRCD(C), Georgia Robins
Sadler, BSN, MBA, PhD. Oral and Dental Management Related
to Radiation Therapy for Head and Neck Cancer. J Can Dent
Assoc 2003; 69(9):585–90.
2. Jay Lucas, DMD, MD, David Rombach, DMD, MD, Joel
Goldwein, MD. Effects of Radiotherapy on the Oral Cavity.
November 1, 2001.
3. Virendra Singh M.D.S., Sunita Malik M.D.S. Oral Care Of Patients
Undergoing Chemotherapy And Radiotherapy: A Review Of
Clinical Approach. The Internet Journal of Radiology ISSN: 1528-
8404.