Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-10-24, 06:08:22 | version 1.58.2
19Dental Tribune Middle East & Africa Edition | September - October 2013 researcH in these areas. Therefore, the patient needs to be informed of the potential life-long risk before radiation therapy is initiated, even if the teeth are very healthy. e. Patient finances If the patient cannot afford dental care that is required after radiation therapy, serious consideration needs to be given as to whether any teeth should remain in the proposed high dose field of radiation. f. Patient compliance If the patient has demonstrated lack of motivation in previous dental care and oral hygiene, or has a severe dental phobia, serious consideration needs to be given whether any teeth should remain in the proposed high dose field of radiation. 1.2.2. dental Factors a. Radiographs A panoramic radiograph should be taken prior to radiotherapy to assess health of the teeth and jaws. Patients without teeth should also have a panoramic film. Other intraoral ra- diographs may be necessary, and even imaging techniques when justified. b. Periodontal disease Teeth in the proposed high dose field of radiation should be considered for pre-radiation therapy extraction if periodontal sulcular depths are equal to or greater than 5mm, if there is fur- cation involvement, if they have a his- tory of refractory periodontitis, tooth mobility, bleeding, or inflammation of the gums. c. Caries (tooth decay) Teeth in the proposed high dose field of radiation should be considered for pre-radiation therapy extraction if they have deep decay, especially in a patient that has numerous areas of tooth decay throughout the oral cav- ity. d. Root canals Teeth having root canals in the pro- posed high dose field of radiation should be considered for pre-radia- tion therapy extraction if they have silver points and/or evidence of root canal failure, i.e. pain, swelling or api- cal radiolucencies. e. Impactions Impacted teeth, especially third mo- lars, that will be located in the pro- posed high dose field of radiation should be extracted prior to radia- tion, if there is pathology associated with the teeth or if the teeth have a communication with the oral cavity. f. Large fillings, fractures, occlusal wear Teeth with large fillings, fractures or significant occlusal wear should be considered for extraction prior to re- ceiving high dose radiotherapy. g. Pain, apical radiolucency Teeth that are painful, have a history of pain, sensitivity to percussion or apical radiolucency should be consid- ered for extraction prior to receiving high dose radiotherapy. h. Unopposed teeth Teeth that do not have contact with a tooth in the opposing arch should be considered for extraction prior to receiving high dose radiotherapy, if they are in the proposed high dose radiation field. 2. management during treatment It is extremely important to keep the mouth clean and healthy during head and neck radiation, to help reduce the risk of oral infection. A professional dental cleaning prior to radiation is highly recommended. Following are some suggestions for reducing oral complications during head and neck radiation.7,9 Monitor the patient’s oral hygiene. Tooth brushing should be performed at least twice daily. Supersoft tooth- brushes* are available that will not cause irritation, Flossing is recom- mended as well as the use of a water- irrigating device, on a low setting, to eliminate food between teeth. Watch for mucositis and infection. Treating infections as soon as they are detected will help to reduce pain, as well as the spread of infection. A fun- gal, bacterial or viral culture is rec- ommended if infection is suspected. Maintaining a self-care regimen may decrease the incidence of mucosi- tis.1,4,9 Advise against wearing remov- able appliances during treatment or left out at night.1,9 3. management after treatment • Recall the patient for prophylaxis and home care evaluation every 4 to 8 weeks or as needed for the first 6 months after cancer treatment. • Reinforce the importance of optimal oral hygiene. • Monitor the patient for trismus: check for pain or weakness in masti- cating muscles in the radiation field. Instruct the patient to exercise three times a day, opening and closing the mouth as far as possible without pain; repeat 20 times. • Consult with the oncology team about use of dentures and other ap- pliances after mucositis subsides. Pa- tients with friable tissues and xeros- tomia may not be able to wear them again. • Watch for demineralization and caries. Lifelong, daily applications of fluoride gel are needed for patients with xerostomia. • Advise against elective oral surgery on irradiated bone because of the risk of osteonecrosis. Tooth extraction, if unavoidable, should be conservative, using antibiotic coverage and possibly hyperbaric oxygen therapy.7,9 4. clinical case 1 Post radiation osteoradionecrosis of the mandible (courtesy Pr. Marcel Noujeim). The patient has a history of radio- therapy for the treatment of tonsilar carcinoma; he is currently undergo- ing hyperbaric-oxygen therapy. A mandibular CBCT showed Ill de- fined, low density areas in the right and left mandibular molar regions (fig.1). On the right side, the area is extending from tooth #43 to distal of tooth #47 and occupying the superior half of the mandible (fig.2). On the left side, the area is extending from tooth #36 to tooth #34 and is also occupying the superior half of the mandible; some granular opacities are noted within the region of inter- est (fig.3). Both areas are associated with interruptions of the lingual and superior cortices. No root resorption could be detected on any of the in- volved teeth. 5. clinical case 2 Post radiation spontaneous mandibu- lar fracture. The patient complains from pain af- ter extraction and curettage of the wound. The CBCT of the angle of the man- dible shows an incomplete healing in the site of extraction, with ill-defined borders, discontinuity of the mandib- ular borders and bone sequestration (fig.4-6). conclusion The clinical management of carcino- mas of the head and neck region caus- es oral sequelae that can compromise patients’ quality of life and necessitate abandonment or reduction of optimal therapeutic regimens, which in turn reduces the odds of long-term sur- vival. Such sequelae can be prevented or at least better managed if dental and medical health care providers work together. It is therefore essential that dentists have an understanding of cancer therapy and a sound work- ing knowledge of the prevention and management options for the oral se- quelae of cancer treatment. The careful, thorough consideration of the complications of radiotherapy and chemotherapy must be consid- ered so measures can be undertaken in every phase of treatment to allevi- ate undue patient discomfort and suf- fering. It is the responsibility of the general dental practitioner to help the patient navigate the minefield of the potentially devastating legacies of cancer therapy. So your oral health needs to be as good as possible before the start of treatment to avoid prob- lems later.3.11 references 1. Hancock JP., Epstein BJ. and Sadler R.G. Oral and Dental Management Related to Radiation Therapy for Head and Neck Cancer. J Can Dent Assoc 2003; 69(9): 585-90. Rest of references is available from the author. Professor ibrahim nasseH, DDS, PhD (Paris), Fellow of the International College of Dentists Director, Oral and Maxillofacial Ra- diology postgraduate program Department of DentoMaxilloFacial Imaging, Lebanese University, School of Dentistry Consultant at Lumiray®, 3D Dental Imaging Center, Beirut, LEBANON ibrahim.nasseh@gmail.com tel: +9613302232 dr. saydé soKHn BDS, DUA, DUB Head of Service, Department of DentoMaxilloFacial Imaging, Lebanese University, School of Den- tistry, Beirut, LEBANON ssokhn@corpocare.com tel: +9613255442 Contact Information Fig.6: 3D representation