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Vol. 00 No. 00 && 2021

Awareness of the risk of radiation-related caries in

patients with head and neck cancer: A survey of
physicians, dentists, and patients
Beatriz Nascimento Figueiredo Lebre Martins, DDS,a Nat
alia Rangel Palmier, DDS, MSc,a,b
Ana Carolina Prado-Ribeiro, DDS, MSc, PhD,a,b Mario Fernando de Goes, DDS, MSc, PhD,c
Marcio Ajudarte Lopes, DDS, MSc, PhD,a Thais Bianca Brand~ao, DDS, MSc, PhD,b
Cesar Rivera, DDS, MSc, PhD,d C
esar Augusto Migliorati, DDS, MSc, PhD,e
Joel B. Epstein, DMD, MSD, FRCD, FDS RCS (E),f,g and Alan Roger Santos-Silva, DDS, MSc, PhDa

Objectives. Radiation-related caries (RRC) is one of the most aggressive complications of radiotherapy (RT) in survivors of head
and neck cancer (HNC). Lack of RRC awareness may contribute to the occurrence of this oral cavity complication. RRC may be
considered a “forgotten oral complication” by patients with HNC, oncologists, and dentists. The present study aimed to assess the
level of awareness of RRC among physicians, dentists, and patients.
Study Design. Physicians (group 1, G1), dentists (group 2, G2), and patients with HNC undergoing RT (group 3, G3) answered
questionnaires concerning their awareness of RRC. Physicians (G1) were divided into group 1A (oncological experience) and
group 1B (general physicians/other specialties). Dentists (G2) were divided into group 2A (oncological experience) and group 2B
(general dentists/other specialties). Personalized questionnaires were designed for each group.
Results. Recruitment was as follows: physicians (n = 124): 1A (n = 64), 1B (n = 60); dentists: (n = 280), 2A (n = 160), 2B (n = 120).
In addition, 58 patients answered the questionnaire. In terms of RRC awareness, 46.77% of physicians, 81.78% of dentists, and
24.13% of patients had some knowledge of the problem.
Conclusion. Patient awareness of RRC was poor. The heterogeneity of answers among physicians and dentists suggests an oppor-
tunity to improve patient education and prevention of this serious oral complication of RT. (Oral Surg Oral Med Oral Pathol Oral
Radiol 2021;000:1 11)

In 2018, approximately 888,000 new cases of head for HNC and can be used alone or combined with sur-
and neck cancer (HNC) were diagnosed worldwide. gery and chemotherapy.2 Worldwide it is estimated
Despite improvement in early diagnosis and therapy, that around 75% of patients with HNC and squamous
there were 453,000 deaths attributed to the disease.1 cell carcinoma (SCC) will be submitted to RT proto-
Radiotherapy (RT) is an important treatment modality cols as primary of adjuvant treatment modality.3
Regardless of the treatment success, it can have damag-
ing effects on normal tissue4,5 surrounding the tumoral
Beatriz Nascimento Figueiredo Lebre Martins and Nat
alia Rangel targeted areas and lead to a series of acute and chronic
Palmier are co-first authors.This study was financed in part by the toxicities that have been documented in the literature.6
Coordenaç~ao de Aperfeiçoamento de Pessoal de N
ıvel Superior
One serious complication of RT in survivors of HNC
Brasil (CAPES) (Finance Code 001). The authors thank S~ao Paulo
Research Foundation (FAPESP) for financial support (Process Nos. is radiation-related caries (RRC). This complication
2018/04657-8, 2018/02233-6, 2016/22862-2, 2013/18402-8, and affects up to 29% of patients irradiated for HNC, which
2012/06138-1), as well as the National Council for Scientific and can increase to 37% after 2 years after RT.7 RRC can
Technological Development (CNPq), Brazil. lead to generalized destruction of teeth, loss of mastica-
a
University of Campinas (UNICAMP), Oral Diagnosis Department,
tory efficiency, chronic infection, and increased risk of
Piracicaba Dental School, Piracicaba, SP, Brazil.
b
Instituto do C^ancer do Estado de S~ao Paulo (ICESP-FMUSP), Den- developing osteoradionecrosis,7,8 which affects patients’
tal Oncology Service, S~ao Paulo, SP, Brazil. quality of life.7-9 RRC differs from conventional caries
c
University of Campinas (UNICAMP), Oral Rehabilitation Depart- in nonirradiated patients, in terms of both onset and
ment, Piracicaba Dental School, Piracicaba, SP, Brazil.
d
Department of Basic Biomedical Sciences, Universidad de Talca,
Talca, Chile.
e
Statement of Clinical Relevance
College of Dentistry, University of Florida, Gainesville, FL, USA.
f
Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Health Radiation-related caries (RRC) may be considered a
System, Los Angeles, CA, USA. “forgotten oral complication” of radiotherapy. Lack
g
City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
Received for publication Mar 11, 2021; returned for revision May 27,
of RRC awareness by physicians and dentists in the
2021; accepted for publication Jun 13, 2021. oncology field could impair the provision of accu-
Ó 2021 Elsevier Inc. All rights reserved. rate information to patients, consequently, affecting
2212-4403/$-see front matter patients’ understanding of RRC.
https://doi.org/10.1016/j.oooo.2021.06.011

1
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2 Martins et al.
progression and clinical presentation. RRC usually starts
as blackish-brown color alteration and the development
of enamel cracks that promote enamel breakage or frac-
ture and, consequently, rapid destruction of the underly-
ing dentin. It mainly affects areas of the cusp, incisal
border, and cervical region leading, in more severe
cases, to amputation of the dental crown.2,10-13
The etiology of RRC is still not fully understood, and
the ability of RT to cause direct radiogenic damage to the
dentition leading to RRC has been discussed in the litera-
ture.14,15 However, studies have shown that the clustering
of oral symptoms using contemporary concepts has led to
new ideas for the analysis of RRC pathogenesis.16 This
clustering includes concurrent mucositis, taste changes,
oral infections, oral pain, trismus, hyposalivation, altered
saliva composition, and shifts in the composition of the
oral microbiota, which, associated with dietary changes
and deficient oral hygiene, lead to the development of a
highly cariogenic oral environment, working in synergy to
increase the risk for RRC development and progres-
sion.4,16-18 RRC restorative treatment can be challenging
owing to altered dental substrate and a hostile oral envi-
ronment. A recent systematic review showed that resin
composite restorations and fluoride supplementation may
be the best alternative for the treatment of RRC; neverthe-
less, the longevity of dental restorations post head and
neck radiotherapy (HNRT) is still remarkably lower com-
pared with conventional restorations in nonirradiated
patients.19 Counseling patients before, during, and after
RT could improve awareness of the complications of RT
and, consequently, improve patients’ compliance with
RRC preventive measures.2,20-23
Awareness studies are widely used to assess knowl-
edge or perception of a specific health issue or dis-
ease.24 Orfei et al.25 reported that lack of awareness
can significantly affect the course of a disease and con-
sequently its prognosis. Hence, awareness is essential
to encourage more proactive behavior toward disease
prevention and health promotion.26 This scientifically
based strategy also provides the recognition of critical
points that must be improved on a given health topic,
in addition to improving communication between pro-
fessionals and their patients.
Previously published studies have been carried out to
assess the level of knowledge of physicians,27 dentists,28
and patients29,30 concerning awareness of the develop-
ment of oral complications secondary to cancer treatment.
In this context, studies have shown that RRC as an
adverse effect of RT is unknown by patients.8,30 Thus,
RRC still poses a major challenge for multi-professional
teams in the oncology setting. Thus, we investigated the
level of awareness of RRC among physicians, dentists,
and survivors of HNC. We considered knowledge in early
diagnosis, referral for dental evaluation before initiation
of cancer therapy, assessment of adequate prevention,
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&& 2021
and treatment aimed at better dental prognosis and
improved quality of life for survivors.
MATERIALS AND METHODS
The present study was a collaboration between dental
professionals of Piracicaba Dental School, University of
Campinas (UNICAMP), Brazil, and of the Dental Oncol-
ogy Service of the S~ao Paulo State Cancer Institute
(ICESP-FMUSP), Brazil. This study was approved by
the Ethics Committee for Human Studies at Piracicaba
Dental School (UNICAMP), according to the recommen-
dations of the National Health Council Ministry of
Health of Brazil for research in human patients (Protocol
No. 88571818.8.0000.5418) and was developed accord-
ing to the Strengthening the Reporting of Observational
Studies in Epidemiology statement guidelines.31
Sample and data collection
This was a cross-sectional study using questionnaires
developed to assess the level of awareness of RRC among
physicians, dentists, and patients . Physicians (oncolo-
gists, head and neck surgeons, radiation oncologists, and
general practitioners), dentists (general practitioners, oral
medicine specialists, and oral oncologists working in can-
cer centers), and patients treated with RT for oral-oropha-
ryngeal SCC were recruited for the study.
Physicians. Physicians were divided into groups as fol-
lows: group 1A: oncologists, head and neck surgeons,
and radiation oncologists; group 1B: physicians with no
experience with patients with HNC. The locations for
recruitment of physicians included hospitals that offered
clinical oncology services and medical professionals in
private clinics or offices. Contact with health professio-
nals was made through an active search by sharing the
questionnaire weblink to professionals at different hos-
pitals, clinics, and locations to reduce bias in the results.
Clinical data, such as training time, residency, and/or
specialty and areas of expertise, were obtained for later
comparison of results. All physicians who agreed to par-
ticipate answered the same questionnaire with 8 ques-
tions related to RRC using SurveyMonkey
(SurveyMonkey Inc., San Mateo, CA, USA).32,33
Dentists. Dentists were recruited as follows: group 2A:
oral medicine practitioners or dentists working in can-
cer treatment facilities and group 2B: dentists who do
not focus their activities on the management of oncol-
ogy patients. The locations for recruitment of dentists
were Piracicaba Dental School, University of Campi-
nas, Brazil; cancer hospitals with dentistry services;
and dentists working in private practice. Contact with
health professionals was made via e-mail after an
active search of the Brazilian Society of Oral Medicine
and Oral Pathology databases. Selection was carried
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Volume 00, Number 00 Martins et al. 3

out in different hospitals, clinics, and locations to
reduce bias in the results. Clinical data, such as training
time, residency, and/or specialization courses and areas
of expertise, were obtained for later comparison of
results. All selected dentists received the same ques-
tionnaire with 13 questions related to RRC ussinng
SurveyMonkey (SurveyMonkey).32,33
Patients. Patients with oral and oropharyngeal SCC
subjected to RT at ICESP-FMUSP were recruited.
Inclusion criteria included patients who underwent
dental evaluation, including oral hygiene and mouth
conditioning protocols, before the beginning of onco-
logic treatment, where patients were instructed both
verbally and in written form of the adverse effects of
RT. Additionally, all patients were evaluated daily by
the dentists’ team throughout RT and the orientation
regarding oral complications of RT were reinforced
throughout the treatment course.8,21
The questionnaire was administered in the last week
of HNRT between the 30th and 35th RT sessions. All
patients received the same questionnaire with 7 ques-
tions related to RRC. Patient questionnaires were pre-
sented by the same trained dental surgeon (N.R.P.).
When patients could not read or did not fully understand
any of the questions, the dental surgeon responsible for
presenting the questionnaire explained the questions
(Supplemental Material S1).
For data analysis, the patients were divided into 3
groups according to their education level: group 3A:
incomplete elementary education; 3B: complete ele-
mentary and/or high school and incomplete higher edu-
cation; 3C: complete higher education (university
education).34 Patients were also divided into 2 groups
according to their clinical stage of disease (I/II and III/
IV), according to the American Joint Committee on
Cancer Staging System35,36 and further divided into 2
groups according to the number of teeth present in the
mouth at the time of assessment: group 3D (3-17 teeth)
and group 3E (18-32 teeth).
Statistical analysis
Answers to the 3 questionnaires were grouped in
Microsoft Office Excel 2019 (Microsoft 365; Microsoft
Corp) for descriptive statistical analysis. Demographic
profile data and questionnaire answers for the 3 groups
were descriptively analyzed, and the results were
assessed using absolute values and percentages. Mean
values were used to analyze patient age. The effect of
time in the specialty and awareness of RRC was ana-
lyzed. Chi-square tests were used to correlate the data
within the physician (1A and 2A), dentist (1B and 2B),
and patient (3A-3E) groups. Chi-square tests were used
to correlate the data between physicians, dentists, and
patients.
Because the contact with health professionals (physi-
cians and dentists) was made through an active search,
different hospitals, clinics, and locations, it was not
possible to measure how many professionals declined
to participate in the present study. All contacted

Table I. Demographic characteristics of physicians included in this study.

Demographic features Physicians group Physicians group Total, n (%)
1A, n (%) 1B, n (%)
Sex
Male 43 (67.18) 33 (55) 76 (61.29)
Female 21 (32.81) 27 (45) 48 (38.70)
Age (years)
20-30 9 (14.06) 38 (63.33) 47 (37.90)
31-40 23 (35.93) 9 (15) 32 (25.80)
41-50 16 (25) 7 (11.6) 23 (18.54)
51-60 8 (12.5) 4 (6.6) 12 (9.67)
>60 8 (12.5) 2 (3.33) 10 (8.06)
Specialty
Head and neck surgeons 40 (62.50) 0 40 (32.25)
Radiotherapists 17 (26.56) 0 17 (13.7)
Oncologists 7 (10.95) 0 7 (5.64)
General physicians 0 49 (81.66) 49 (39.51)
Others 0 11 (18.34) 11 (8.87)
Time in the specialty
(years)
<5 14 (21.87) 41 (68.33) 55 (44.35)
5-10 15 (23.43) 4 (6.66) 19 (15.32)
10-20 15 (23.43) 7 (11.66) 22 (17.74)
>20 20 (31.25) 8 (13.3) 28 (22.58)
Physicians group 1A: head and neck surgeons, radiotherapists, or oncologists; physicians group 1B: general practice physicians, cardiologists, dermatolo-
gists, endoscopists, army or occupational physicians, neurologists, otorhinolaryngologists, pediatricians, psychiatrists, radiologists, and urologists.
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Table II. Demographic characteristics of dentists included in this study.

Demographic features Dentists group 2A, n (%) Dentists group 2B, n (%) Total, n (%)
Sex
Male 54 (33.75) 31 (25.83) 85 (30.35)
Female 106 (66.25) 89 (74.16) 195 (69.64)
Age (years)
20-30 62 (38.75) 53 (44.16) 115 (41.07)
31-40 57 (35.62) 40 (33.33) 97 (34.64)
41-50 28 (17.5) 12 (10) 40 (14.28)
51-60 8 (5) 11 (9.16) 19 (6.7)
>60 5 (3.12) 4 (3.33) 9 (3.21)
Specialty
Oral medicine or dentists working with oncological dentistry 160 (100) 0 160 (57.14)
Oral and maxillofacial surgery* 0 25 (20.83) 25 (8.93)
Orthodontics 0 21 (17.5) 21 (7.5)
Oral rehabilitation 0 20 (16.66) 20 (7.14)
Pediatric dentistry 0 14 (11.66) 14 (5)
Endodontics 0 13 (10.83) 13 (4.64)
Dentistry 0 11 (9.16) 11 (3.93)
Periodontics 0 10 (8.33) 10 (3.57)
Social/legal dentistry 0 6 (5) 6 (2.14)
Time in the specialty (years)
<5 68 (42.5) 55 (45.83) 123 (43.92)
5-10 19 (11.87) 17 (14.16) 36 (12.85)
10-20 30 (18.75) 21 (17.5) 51 (18.21)
>20 43 (26.87) 27 (22.5) 70 (25)
Dentists group 2A: Oral medicine or dentists working with oncological dentistry; dentists group 2B: oral and maxillofacial surgery (*with no
experience in oncological centers or patients with head and neck cancer patients), orthodontics, oral rehabilitation, pediatric dentistry, endodon-
tics, dentistry, periodontics, and social/legal dentistry.

patients agreed to participate in the study by answering
the questionnaire.
RESULTS
In a total, 458 individuals participated in the surveys,
as follows: 124 physicians: oncologists, head and neck
surgeons, and radiation oncologists (n = 64) and gen-
eral physicians (n = 60); 280 dentists: oral medicine
practitioners or dentists working in cancer treatment
facilities (n = 160) and general dentists (n = 120); and
58 patients who received RT for treatment of oral-oro-
pharyngeal SCC.
The demographic profile of physicians is shown in
Table I. Seventy-six physicians were male (61.3%) and
48 were female (38.7%). Of these 124 physicians,
group 1A included 40 head and neck surgeons
(62.50%), 17 radiation oncologists (26.56%), and 7
medical oncologists (10.95%), and group 1B included
physicians who had no experience with patients with
HNC (60; 48.38%). Most physicians (55; 44.35%)
were in the specialty for <5 years. The estimated age
of physicians ranged from 25 to 60 years (mean, 38.35
years), with an equal distribution between male and
female physicians.
Of the 280 dentists who replied to the questionnaire,
195 were female (69.64%) and 85 were male
(30.36%). Group 2A included 160 (57.14%) oral
medicine practitioners or dental surgeons working in
oral oncology and group 2B included 120 dental pro-
fessionals (42.86%): 25 oral and maxillofacial sur-
geons (8.93%), 21 orthodontists (7.5%), 20
prosthodontics and oral rehabilitation specialists
(7.16%), 14 pediatric dentists (5%), 13 endodontists
(4.6%), 11 dentistry specialists (3.92%), 10 periodont-
ists (3.57%), and 6 forensic dentistry specialists
(2.14%). Most dental specialists were practicing their
specialty for <5 years (123; 43.93%) (Table II). The
estimated age of dentists was 25 to 60 years, with an
equal distribution between male and female dentists.
Owing to the age range options on the objective ques-
tionnaire, it was not possible to calculate mean age
data for this group. Nevertheless, there was a concen-
tration of dentists between 20 and 30 years old (115;
41.07%) and between 31 and 40 years old (97;
34.64%).
The patient group included 58 participants, of whom
51 were male (87.93%) and 7 were female (12.07%).
Their mean age was 57.3 years (range, 39-72). Primary
tumors were located on the tongue (14, 24.13%), oro-
pharynx (13, 22.41%), retromolar area (5, 8.62%), pal-
ate (4, 6.89), lip (4, 6.89%), larynx (3, 5.17%), and
other sites (13, 25.89%). Most patients were diagnosed
as having advanced clinical stage III (13, 22.41%) and
stage IV (29, 50%) disease. The most frequent
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Table III. Demographic characteristics of patients the 2 groups. Group 2A (78, 48.45%) and group 2B
included in this study. (61, 50.83%) responded approximately 20%, but
among 51.55% of dentists in group 2A and 49.17% in
Variables n (%)
group 2B, answers varied between 5%, 75%, and 90%.
Age (years), mean (range) 57.3 (39-72) Two hundred and sixteen dentists (77.14%) advised
Sex
Male 51 (87.9)
their patients undergoing HNC RT to be evaluated by a
Female 7 (12.1) dentist trained in the field. In addition, 209 (74.64%)
Primary tumor site believed that RRC can lead to osteoradionecrosis.
Tongue 14 (24.13) Patients were grouped according to education level,
Oropharynx 13 (22.41) clinical stage of the disease, and number of teeth pres-
Retromolar trigone 5 (8.62)
Lip 4 (6.89)
ent (Table VI). Most patients (44, 75.86%) were not
Palate 4 (6.89) aware of RRC. Additionally, 38 patients (65.5%)
Larynx 3 (5.17) believed that the decrease in saliva caused by RT could
Other sites 13 (25.89) be associated with RRC (Table VI). Patients with a
Clinical stage higher education level (group 3C) had better overall
Stage I (3.44)
Stage II 7 (12.06)
results relating to their comprehension of the effects of
Stage III 13 (22.41) RT leading to the development of RRC (74.07%).
Stage IV 29 (50) Group 3C also reported being advised by physicians
Unavailable* 7 (12.06) (55.5%) and dentists (77.8%) to see a dental specialist
Treatment in the field at higher frequency than patients with lower
Surgery + RT 13 (22.41)
RCT 28 (48.27)
education levels (groups 3A and 3B) (Table VI).
Surgery + RCT 9 (15.51) More patients (66.66%) in initial stages I/II of disease
Exclusive RT 8 (13.79) reported being advised by their dentists of the possibility
HNRT modality of developing caries after RT than were patients in
3DRT 36 (62.06) advanced clinical stages III/IV (59.52%). This correlation
VMAT 18 (31.03),
IMRT 4 (6.89).
was also observed regarding orientation from the physi-
Mean radiation dose 63.92 Gy cians, where more patients in stages I/II (55.55%) reported
being advised about RRC by their physicians compared
3DRT, 3D conformal radiotherapy; HNRT, Head and neckl radiother-
apy; IMRT, intensity-modulated radiotherapy; RCT, radiochemother-
with patients in stages III/IV (45.23%) (Table VI).
apy; RT, radiotherapy; VMAT, volumetric modulated arc therapy. Patients with a greater number of teeth (group 3E)
*Patients’ cancer staging information was not available in medical had an increased awareness of RRC (30%). They were
charts. more often informed of the effects of RT on RRC
(80%) and were better informed by their physicians
(50%) and dentists (66.6%) that hyposalivation could
oncologic treatment was concomitant radiochemother- lead to the development of RRC (73.3%). All patients
apy (RCT) (28, 48.27%) (Table III). in groups 3D and 3E understood that oral hygiene
The data obtained from physicians are presented in affected the risk of RRC. Similarly, the effect of RRC
Table IV. Regarding RRC awareness, 58 physicians on osteoradionecrosis (ORN) development was under-
(46.77%) were aware of this toxicity. Most physicians stood in both groups (89.28% in group 3D and 86.66%
in group 1A (36; 56.25%) and group 1B (41; 68.33%) in group 3E, respectively) (Table VI).
groups believed that the percentage of patients postirra-
diation who will develop RRC is 20% (P < .03). DISCUSSION
Regarding the approximate time for the development The present study assessed the level of awareness of
of RRC, professionals in group 1A (29, 45.31%) and physicians who work with patients with HNC and gen-
group 1B (29, 48.33%) responded 12 months (P < eral physicians; dentists who work with patients with
0,03), but for 54.69% in group 1A and 51.67% in group cancer and general dentists, and patients with HNC with
1B answered varied from 1 month, 3 months, and 36 a focus on RRC clinical characteristics. Based on recent
months as the time for the development of RRC post- published studies in the field, to our knowledge, this is
HNRT. Seventy-seven physicians advised patients the first study to evaluate awareness of RRC from the
undergoing RT for HNC to be evaluated by dentists perspective of physicians, dentists, and patients.1,7,8,30
(62.09%). RRC is an adverse effect of RT that can lead to wide-
Data obtained from dentists are shown in Table V. spread destruction of teeth, loss of masticatory effi-
Regarding RRC awareness, 229 dentists (81.78%) ciency, and chronic infection and increase the risk for
were aware of this toxicity. Knowledge regarding the the development of osteoradionecrosis, with a direct
approximate incidence of RRC post-RT varied between effect on patients’ quality of life.8,9 These patients may
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Table IV. Physicians’ questionnaire answers.

Questions Physicians group 1A, n (%) Physicians group 1B, n (%) Total, n (%)
Are you aware of the concept of RRC?
Yes 50 (78.12) 8 (13.33) 58 (46.77)
No 14 (21.87) 52 (86.66) 66 (53.22)
Which patients are susceptible to RRC?
Head and neck cancer 63 (98.43) 58 (96.66) 121 (97.58)
Multiple myeloma 1 (1.56) 1 (1.66) 2 (1.61)
Graft vs host disease 0 1 (1.66) 1 (0.80)
Bone marrow transplant 0 0 0
How long (approximately) until the development of RRC (after RT)?
1 month 4 (6.25) 6 (10) 10 (0.80)
3 months 18 (28.12) 20 (33.33) 38 (30.64)
12 months 29 (45.31) 29 (48.33) 58 (46.77)
36 months 13 (20.31) 5 (8.3) 18 (14.51)
Do you believe that RRC can be more aggressive than conventional caries?
Yes 63 (98.43) 52 (86.66) 115 (92.74)
No 1 (1.56) 8 (13.33) 9 (7.25)
What is the approximate percentage of post-RT patients who will develop RRC?
5% 9 (14.06) 15 (25) 24 (19.35)
20% 36 (56.25) 41 (68.33) 77 (62.09)
75% 14 (21.87) 4 (6.66) 18 (14.51)
90% 5 (7.81) 0 5 (4.03)
Do you advise your patients with head and neck cancer undergoing RT to be evaluated by a dentist?
Yes 61 (95.31) 16 (26.66) 77 (62.09)
No 2 (3.12) 14 (23.33) 16 (12.90)
Not applicable 1 (1.56) 30 (50) 31 (25)
Do you advise your patients with head and neck cancer undergoing RT of the risk of developing RRC?
Yes 43 (67.18) 8 (13.33) 51 (41.12)
No 18 (28.12) 22 (36.66) 40 (32.25)
Not applicable 3 (4.68) 30 (50) 33 (26.61)
Do you believe that RRC can lead to osteoradionecrosis?
Yes 60 (93.75) 58 (96.66) 118 (95.16)
No 4 (6.25 2 (3.33) 6 (4.83)

Physicians group 1A: Head and neck surgeons, radiotherapists, or oncologists; physicians group 1B: general practice physicians, cardiologists,
dermatologists, endoscopists, army or occupational physicians, neurologists, otorhinolaryngologists, pediatricians, psychiatrists, radiologists, and
urologists.
RRC, radiation-related caries; RT, radiotherapy.

choose to avoid social interaction, eating, conversation,
laughing, smiling, and engaging in relationship behav-
iors such as kissing because of the embarrassment asso-
ciated with the appearance of their teeth.9,37-39
Although RRC was first described more than
80 years ago,40 our results showed that only 46.77% of
physicians were aware of it in relation to HNC treat-
ment. This lack of awareness can compromise the
safety of their patients and expose them to serious
problems that could be prevented.41
Overall, physicians and dentists answered most of
the questions correctly. Previous studies regarding
other oral complications of head and neck RT reported
that this high rate of correct answers could be
explained by the way the data collection was carried
out because the questionnaires were designed to be
completed in approximately 5 minutes.27
When comparing the answers within physician groups
1A and 1B, the answers varied. This divergence stands
out for the question regarding the approximate time for
the development of RRC, where group 1A (45.31%) and
group 1B (48.33%) reported that the approximate time
for the development of RRC is 12 months, but answers
from 54.69% in group 1A and 51.67% in group 1B varied
between 1 month, 3 months, and 36 months, showing that
less than half knew the time for onset and progression of
RRC. It is known that RRC begins within the first year
(6-12 months) after HNRT. The first clinical changes in
tooth structure include demineralization of enamel and
dentin, the development of cracks and fissures that pro-
mote enamel breakage or fracture, cavitation with struc-
ture loss, discoloration of tooth structure, and, with the
progression of tooth structure, destruction leading to
amputation of the dental crown.8,13 Thus, the lack of
knowledge among physicians treating this patient popula-
tion may lead to a delay in diagnosis of RRC and
increased risk of additional complications after the devel-
opment and progression of structural damage that may
lead to dental fracture, dental abscess, high of risk of
osteoradionecrosis, and decreased quality of life.8,9
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Volume 00, Number 00 Martins et al. 7

Table V. Dentists’ questionnaire answers.

Questions Dentists group 2A, n (%) Dentists group 2B, n (%) Total, n (%)
Are you aware of the concept of RRC?
Yes 155 (97) 74 (46) 229 (81.78)
No 5 (3) 46 (29) 51 (18.21)
Which patients are susceptible to RRC?
Head and neck cancer 160 (100) 119 (99) 279 (99.64)
Multiple myeloma 0 1 (1) 1 (0.35)
Graft vs host disease 0 0 0
Bone marrow transplant 0 0 0
How long (approximately) until the development of RRC (after RT)?
1 month 31 (19.37) 21 (17.5) 52 (18.57)
3 months 62 (38.75) 55 (45.83) 117 (41.78)
12 months 60 (37.5) 37 (30.83) 97 (34.64)
36 months 7 (4.37) 7 (5.83) 14 (5)
Do you believe that RRC can be more aggressive than conventional caries?
Yes 145 (90.62) 102 (85) 247 (88.21)
No 15 (9.37) 18 (15) 33 (11.79)
What is the approximate percentage of post-RT patients who will develop RRC?
5% 8 (5) 17 (14.17) 25 (8.92)
20% 78 (48.45) 61 (50.83) 139 (49.64)
75% 66 (41.25) 35 (29.17) 101 (36.07)
90% 8 (5) 7 (5.83) 15 (5.35)
Do you believe that RRC develops:
Proximal region, scars, and fissures? 11 (6.87) 27 (22.5) 38 (13.57)
Cervical region, incisal edge, and cusp tip? 149 (93.12) 93 (77.5) 242 (86.42)
Do you advise your patients with head and neck cancer undergoing RT o be evaluated by a specialist dentist in the field?
Yes 129 (80.62) 87 (72.5) 216 (77.14)
No 7 (4.3) 17 (14.16) 24 (8.57)
Not applicable 24 (15) 16 (13.33) 40 (14.28)
Do you advise your patients with head and neck cancer undergoing RT of the risk of developing RRC?
Yes 147 (91.87) 77 (64.16) 224 (80)
No 2 (1.25) 23 (19.16) 25 (8.92)
Not applicable 11 (6.87) 20 (16.66) 31 (11.07)
Do you believe that RRC can present as blackish-brown spots?
Yes 155 (96.87) 99 (82.5) 254 (90.71)
No 5 (3.12) 21(17.5) 26 (9.28)
Do you believe that cracks and enamel cracks can be part of the spectrum of RRC?
Yes 98 (61.25) 70 (58.33) 168 (60)
No 62 (38.75) 50 (41.66) 112 (40)
Do you believe that RRC can lead to enamel delamination or amputation of the dental crown?
Yes 148 (92.5) 107 (89.16) 255 (91.07)
No 12 (7.5) 13 (10.83) 25 (8.92)
Do you believe that RRC can lead to osteoradionecrosis?
Yes 129 (80.62) 80 (66.66) 209 (74.64)
No 31 (19.37) 40 (33.33) 71 (25.35)
Do you believe that the RRC restorative treatment has the same longevity as conventional caries restorative treatment?
Yes 25 (15.62) 41 (34.16) 66 (23.57)
No 135 (84.37) 79 (65.83) 214 (76.42)

Dentists group 2A: Oral medicine or dentists working with oncological dentistry; dentists group 2B: oral and maxillofacial surgery, orthodontics,
oral rehabilitation, pediatric dentistry, endodontics, dentistry, periodontics, social/legal dentistry.
RRC, radiation-related caries; RT, radiotherapy.

Most dentists (81.78%) reported that they were
aware of RRC. This was expected because dental care
programs for patients with HNC have been well docu-
mented in the literature.42-44 In addition to decreasing
the risk of oral toxicity, preventive dental care pro-
grams can lower the cost of treatment in hospitalized
patients.45-50 For instance, the global cost of RRC man-
agement ranges from $192 to $4500.51 However,
knowledge of RRC varied between the groups of den-
tists, reinforcing the need for better education of dental
professionals on the unique aspects of RRC and how to
best manage patients with HNC undergoing RT.52
Patients undergoing RT should receive intensive oral
hygiene instructions, high-potency fluoride applica-
tions, salivary stimulation and antimicrobial therapy
when indicated, dietary advice, and regular dental
 8 Martins et al.
ORAL MEDICINE
Table VI. Patient questionnaire answers by subgroup.
Level of education, n (%) Cancer staging, n (%) No. of teeth, n (%) Total, n (%)
Questions 3A 3B 3C I-II III-IV Unavailable* 3D 3E
Are you aware of the concept of RRC?
Yes 1 (25) 6 (22.22) 7 (25.92) 1 (11.11) 11 (26.19) 5 (17.85) 5 (17.85) 9 (30) 14 (24.13)
No 3 (75) 21 (77.78) 20 (74.07) 8 (88.88) 31 (73.80) 23 (82.14) 23 (82.14) 21 (70) 44 (75.86)

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Do you believe that radiation can affect teeth, leading to caries?
Yes 2 (50) 8 (29.62) 20 (74.07) 8 (88.89) 29 (69.04) 19 (67.85) 19 (67.85) 24 (80) 30 (51.72)
No 2 (50) 19 (70.37) 7 (25.92) 1 (11.11) 13 (30.95) 9 (32.14) 9 (32.14) 6 (20) 28 (48.27)
Were you advised by your physician of the possibility of developing caries after RT?
Yes 1 (25) 10 (37.03) 15 (55.55) 5 (55.55) 19 (45.23) 11 (39.28) 11 (39.28) 15 (50) 26 (44.82)
No 3 (75) 17 (62.96) 12 (44.45) 4 (44.44) 23 (54.76 17 (60.71) 17 (60.71) 15 (50) 32 (55.18)
Were you advised by your dentist of the possibility of developing caries after RT?
Yes 1 (25) 12 (44.45) 21 (77.78) 6 (66.66) 25 (59.52) 14 (50) 14 (50) 20 (66.66) 34 (58.62)
No 3 (75) 15 (55.55) 6 (22.22) 3 (33.33) 17 (40.47) 14 (50) 14 (50) 10 (33.33) 24 (41.37)
Do you believe that RT-related hyposalivation increases the risk of the development of RRC?
Yes 4 (100) 17 (62.96) 17 (62.96) 5 (55.55) 28 (66.66) 16 (57.14) 16 (57.14) 22 (73.33) 38 (65.51)
No 0 10 (37.04) 10 (37.04) 4 (44.44) 14 (33.33) 12 (42.85) 12 (42.85) 8 (26.66) 20 (34.49)
Do you believe that good oral hygiene can help prevent the development of RRC?
Yes 4 (100) 27 (100) 27 (100) 9 (100) 42 (100) 28 (100) 28 (100) 30 (100) 58 (100)
No 0 0 0 0 0 0 0 0 0
Do you believe that RRC can lead to osteoradionecrosis?
Yes 4 (100) 23 (85.18) 24 (88.88) 7 (77.77) 39 (92.85) 25 (89.28) 25 (89.28) 26 (86.66) 51 (87.94)
No 0 4 (14.82) 3 (11.12) 2 (22.22) 3 (7.14) 3 (10.71) 3 (10.71) 4 (13.33) 7 (12.06)
3A: complete elementary; 3B2: incomplete high school and complete high school or incomplete higher education; 3C: complete higher education university education; 3D: 3 to 17 teeth present in mouth; and
3E: 18 to 30 teeth present in mouth.
RRC, radiation-related caries; RT, radiotherapy.
*Patients’ cancer staging information was not available in medical charts.

&& 2021
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Volume 00, Number 00
follow-up before, during, and after treatment to prevent
dental complications. Pre-RT dental evaluation and
indicated treatment with a preventive program for car-
ies reduction to reduce the need for tooth extractions
post-RT and minimize the risk of osteoradionecrosis
should also be performed.53,54
RRC can lead to the destruction of teeth and associ-
ated dental infection.4,7,8 Dental extractions may need
to be avoided in teeth in the high dose radiated volume
owing to risk of osteoradionecrosis.8,51 Nevertheless,
25.35% of dentists do not believe that RRC can lead to
osteoradionecrosis. This lack of knowledge can lead to
inappropriate treatment that can affect the course of the
disease and lead to complications of RT.25
Awareness is essential to encourage proactive
behavior related to disease and promote health.26 How-
ever, studies have shown that without close interdisci-
plinary cooperation, communication gaps may occur
between physicians, dentists, and patients. The lack of
communication might increase the risk of complica-
tions.29 Therefore, irradiated patients are at significant
risk of potentially debilitating oral complications,
which can be prevented or at least more appropriately
managed if dental and medical health care providers
work together in an interprofessional fashion.55,56
As previously mentioned, all patients included in the
present study were instructed both verbally and in writ-
ten form of the adverse effects of RT. The guidelines
covering RRC and other toxicities were reinforced at
every dental appointment.8,28 Nevertheless, 75% of
patients were not aware of RRC. This lack of patient
awareness may be explained in part by the inadequate
education of health professionals and the lack of inter-
est in the problem on the part of patients being treated
for cancer.29,30 Another reason could be the lack of
knowledge among health professionals who do not
educate patients on the effect of cancer therapy on den-
tal health and the risk of RRC.27
Patients’ level of education, as observed in Table VI,
may explain differences in the way patients answered the
questionnaires. Although not statistically significant,
patients with a higher level of education (group 3C)
answered more questions correctly compared with those
with a lower level of education (groups 3A and 3B). Edu-
cation contributes to the development of a range of skills
and traits, such as cognitive skills, problem-solving abil-
ity, learning effectiveness, and personal control.57
Table VI shows a trend that patients with a greater num-
ber of teeth (18-30) answered more questions correctly.
This suggests that patients with better oral health may be
more aware and maintain good oral and dental health.
These patients may also pay more attention to instructions
regarding necessary oral care during and after HNRT.58
Fernandes et al.30 reported similar results regarding
the low level of awareness among patients. In their
ORIGINAL ARTICLE
Martins et al. 9
study, osteoradionecrosis was the most unknown toxic-
ity of RT, followed by RRC (43%).30 Patients in the
present study presented a remarkably higher lack of
awareness of RRC (75.86%) compared with patients
who were advised of RT complications with an educa-
tional video,30 which reinforces the need for better
strategies for the delivery of information regarding pos-
sible complications of HNRT. Results also corroborate
the literature assessment of the level of awareness
regarding other oral toxicities of cancer treatment, such
as oral mucositis, among physicians, dentists, and
patients, which also reported a low level of aware-
ness.59-63
All patients with HNC treated with RT should be
aware of the importance of oral hygiene. Epstein
et al.64 suggested that patients’ dental behaviors are
more positive when recommendations are delivered by
oncology professionals. However, the present study
demonstrated that 55.18% of patients reported that
they were not advised by their physicians of the risk of
developing RRC. On the other hand, 58.62% of
patients reported that they were advised by dentists of
the possibility of developing RRC. Nevertheless, both
results are low considering that only approximately
half of patients reported being advised by a physician
or dentist of the risk of developing RRC. Even health
care professionals who do not regularly work with
patients with HNC should have knowledge regarding
this complication of RT, considering that with advan-
ces in cancer treatment and increase in overall survival
rates these patients may require assistance from a vari-
ety of health care providers in addition to physicians
and dentists who work in oncology.65-68
CONCLUSIONS
Patients with HNC had limited awareness of RRC.
Despite the percentage of correct answers, the hetero-
geneity of answers among physicians and dentists may
be an important factor in how the information is pre-
sented to patients and caregivers. The lack of aware-
ness impairs the provision of accurate information to
patients, consequently affecting patients’ understand-
ing of RRC. Strategies for further dissemination and
better communication between health care providers
and patients in addition to measures to prevent RRC
must be established to provide the best care for these
patients.
ACKNOWLEDGMENTS
We thank the Brazilian Society of Stomatology
(SOBEP) for their support in sending questionnaires to
the participants.
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ORAL MEDICINE
10 Martins et al.
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Reprint requests:
Nat
alia Rangel Palmier DDS, MSc.
Dental Oncology Service
Instituto do C^ancer do
Estado de S~ao Paulo
(ICESP-FMUSP)
Av. Dr Arnaldo 51
Cerqueira C
esar
S~ao Paulo
SP 01246-000
Brazil.
natpalmier@gmail.com, alan@unicamp.br
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11.e1 Martins et al. && 2021

APPENDIX