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18 Dental Tribune Middle East & Africa Edition | September - October 2013researcH Fig.3: Left side Fig.4: Lateral view I ntroduction Surgery, chemotherapy and ra- diotherapy are the options for treatment of head and neck can- cers. Each modality is associated with a number of considerations related to treatment of the cancer and quality of life of the patient. Radiation therapy plays an important role in the treatment of patients with head and neck cancer. Depending on the location of the malignancy (pri- mary tumor, lymph node metastases), the salivary glands, oral mucosa, and jaws have to be inevitably included in the radiation treatment portals. The complications must be consid- ered thoroughly so that every effort is undertaken to minimize the oral morbidity for these patients before, during and after cancer treatment and throughout the patient’s lifetime. With over 1.4 million new cases of cancer diagnosed each year and a shift to outpatient management, dentists are more likely to see some of these patients in their practice; so they need to know about potential oral side ef- fects. Preexisting or untreated oral disease can also complicate cancer treatment. Such complications can be prevented or at least better managed if dental and medical health care pro- viders work together.1,2 This paper offers the dental team an overview of the consequences asso- ciated with radiotherapy to facilitate collaboration with the patient’s medi- cal team. 1.The role of pre-treatment oral care A thorough oral evaluation by a knowledgeable dentist before cancer treatment begins is important to the success of the regimen. Pretreatment oral care achieves the following: • Reduces the risk and severity of oral complications. • Allows for prompt identification and treatment of existing infections or other problems. • Improves the likelihood that the patient will successfully complete planned cancer treatment. • Prevents, eliminates, or reduces oral pain. • Minimizes oral infections that could lead to potentially serious systemic infections. • Prevents or minimizes complica- tions that compromise nutrition. • Prevents or reduces later incidence of bone necrosis. • Preserves or improves oral health. • Provides an opportunity for patient education about oral hygiene during cancer therapy. • Improves the quality of life. • Decreases the cost of care. 3,4 With a pretreatment oral evaluation, the dental team can identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease that could contribute to oral complications when cancer therapy begins. The evaluation also estab- lishes baseline data for comparing the patient’s status in subsequent exami- nations. Open communication with the pa- tient’s oncologist is essential to ensure that each provider has the informa- tion necessary to deliver the best pos- sible care. 1.1. Pretreatment oral evaluation Ideally, a comprehensive oral evalu- ation should take place 1 month be- fore cancer treatment starts to allow adequate time for recovery from any required invasive dental procedures. The pretreatment evaluation includes a thorough examination of hard and soft tissues, as well as appropriate ra- diographs (panoramic and CBCT) to detect possible sources of infection and pathology.1,5 Also take the following steps before cancer treatment begins: • Identify and treat existing infec- tions, carious and other compromised teeth, and tissue injury or trauma. • Stabilize or eliminate potential sites of infection. • Extract teeth in the radiation field that are nonrestorable or may pose a future problem to prevent later ex- traction-induced osteonecrosis. • Conduct a prosthodontic evaluation if indicated. If a removable prosthesis is worn, make sure that it is clean and well adapted to the tissue. Instruct the patient not to wear the prosthesis during treatment, if possible; or at the least, not to wear it at night. • Perform oral prophylaxis if indi- cated. • Time oral surgery to allow at least 2 weeks for healing before radiation therapy begins. For patients receiving radiation treatment, this is the best time to consider surgical procedures. Oral surgery should be performed at least 7 to 10 days before the patient receives myelosuppressive chemo- therapy. Medical consultation is indi- cated before invasive procedures. • Remove orthodontic bands and brackets if highly stomatotoxic chem- otherapy is planned or if the appli- ances will be in the radiation field. • Consider extracting highly mobile primary teeth in children, and teeth that are expected to exfoliate during treatment. • Prescribe an individualized oral hy- giene regimen to minimize oral com- plications. Patients undergoing head and neck radiation therapy should be instructed on the use of supplemental fluoride. Radiographic examination is es- sential in assessing the presence of abscesses, evaluation of periodontal status and determination of the exist- ence of metastatic disease. Previous dental experience and exposure may also serve as a useful prognostic indi- cator.4,5,6 1.2. Pre-radiotherapy extraction The majority of patients who de- velop osteoradionecrosis (ORN) are those who were dentate just prior to the commencement of radiotherapy. Tooth removal accounts for the vast majority of trauma-related ORN, so all teeth located within the primary beam of the radiation portal should be closely scrutinized. Early consul- tation with the radiation oncologists and therapists is essential. 7,8 A number of factors influence the clinician’s decision as to which teeth need to be removed prior to the com- mencement of radiotherapy. There is still much controversy surrounding the extraction criteria for radiothera- py patients, but the following need to be considered:6,9,10,11 1.2.1. non-dental factors a. Radiation dose If the radiation dose to the bone of the mandible and maxilla is less than 5000cGy, then according to the litera- ture, there should be minimal risk of osteonecrosis after radiotherapy. The radiation oncologist must give this information to the dentist prior to the initiation of head and neck radiation. b. Location of radiation ports At some oral oncology clinics, rec- ommendations for dental extractions prior to radiotherapy are limited to those areas of the mandible and max- illa that are going to receive greater than 5000cGy. If there are teeth out- side the potential high dose field of radiation, that are symptomatic or have a hopeless prognosis, they should be extracted prior to radia- tion, if time permits. c. Patient prognosis If the prognosis of the patient is ex- tremely poor or if the tumor is grow- ing rapidly, the radiation oncologist may decide that radiation needs to proceed without delay. After extrac- tion, 2-3 weeks healing time is recom- mended before head and neck radia- tion therapy begins. d. Patient age The younger the patient, the longer the teeth must be maintained disease free. If dental extractions are required (due to tooth decay or periodontal disease) in areas that will receive high dose radiation, the patient will be at significant risk for osteonecrosis. The risk of osteonecrosis in irradiated ar- eas is present for the duration of the patient’s life. There is no “safe” time limit to wait for extractions or surgery by Professor ibrahim nasseH, dr. saydé soKHn ________________________ Fig.1:Axial view. Fig.2: Right side Oral Management Of Oncology Patients Requiring Radiotherapy Fig.5: Cross sectional views