A review of dental treatment of IN BRIEF

• Describes the immediate and long term

head and neck cancer patients, oral side effects of radiotherapy

PRACTICE
• Highlights the importance and need for
pre-radiotherapy assessment.

before, during and after

radiotherapy: part 1
H. Jawad,*1,2 N. A. Hodson3 and P. J. Nixon4

The incidence of head and neck cancer is on the rise. Most head and neck cancers are treated with surgery, radiotherapy,
chemotherapy or a combination of these modalities. Patients undergoing radiotherapy can experience several unwanted oral side
effects, which have both short and long term implications. Dental general practitioners should be aware of these implications
and should liaise closely with the restorative consultants and the oncology team to establish the best oral care pathway. This
two-part series is a review of the oral changes that occur during and after radiotherapy and the oral management of head
and neck oncology before, during and after radiotherapy. This article deals with both immediate sequelae such as cellulitis,
mucositis, dysphagia, dysguesia and weight loss as well as long term sequelae such as rampant caries, trismus, xerostomia and
osteoradionecrosis. It also encompasses the importance and need for pre-radiotherapy assessment.

INTRODUCTION
The National Head and Neck Cancer audit 2011
stated that there are approximately 7,354 new
cases of head and neck cancer diagnosed in
England and Wales each year, of which the
audit had received 6,879.1 Approximately 90%
of all malignant head and neck tumours are
squamous cell carcinomas (SCC). The disease
burden of head and neck cancer is significant;
patients require intensive multimodality treat-
ments and prolonged rehabilitation with long
term support to achieve an adequate recovery.
The disease significantly impacts on eating,
drinking, speech, swallowing, smell, breath-
ing, social interaction and work capabilities.
Most head and neck cancers are treated with
surgery or radiotherapy or, a combination of
both. Chemotherapy alone is rarely appropri-
ate for these forms of cancer, but chemothera-
peutic agents are increasingly used to enhance
the effects of radiotherapy; this is known as
chemoradiation.
When a diagnosis of head and neck cancer
is made, each individual case is discussed at
a multi-disciplinary team (MDT) meeting to
1
Oral and Maxillofacial Speciality Doctor, St Lukes
Hospital, Bradford; 2Community Dental Officer, Shipley
Health Centre; 3Senior Lecturer/Honorary Consultant in
Restorative Dentistry, School of Medicine and Dentistry,
UCLAN, 4Restorative Consultant, Leeds Dental Institute
*Correspondence to: Miss Huda Jawad
Email: H.jawad@nhs.net
Refereed Paper
Accepted 24 November 2014
DOI: 10.1038/sj.bdj.2015.28
© British Dental Journal 2015; 218: 65-68
consider which treatment(s) may be the best
option. Optimum management of patients
with head and neck cancer requires the active
involvement of experts from a particularly wide
variety of fields. The members of the team con-
sist of: maxillofacial consultant surgeons; ENT
consultant surgeons; consultant oncologists;
consultant radiologists; consultant pathologists;
consultants in restorative dentistry; head and
neck cancer specialist nurse; speech and lan-
guage therapist and dieticians as well as other
doctors and health professionals with an inter-
est in cancer. The restorative consultant has a
key role to report and treat any dental problem
which may interrupt or compromise the course
of cancer treatment. There is an increasing body
of evidence demonstrating that unplanned
interruptions of radical radiotherapy treatment
results in prolonged overall treatment time,
which can detrimentally affect local control and
cure rates for patients with certain tumours. The
tumour types reported in the literature as being
most affected by interruptions include head and
neck squamous cell carcinomas2,3 and cancer
of the oesophagus.4,5 The consultant in restora-
tive dentistry also has a key role in helping to
improve quality of life post-cancer treatment
by maximising oral rehabilitation opportunities
before and following oncological care.
THE ROLE OF THE GENERAL
DENTAL PRACTITIONER
General dental practitioners (GDPs) play an
important role in the primary prevention of
oral cancer through patient education and life-
style counselling in relation to smoking and
alcohol consumption. Patients should be made
aware that smoking and regularly drinking in
excess can increase their risk of oral cancer.
The importance of attending dental appoint-
ments must be highlighted to all patients. They
should be mindful that dental visits are not
only about treating dental disease but to pre-
vent, screen and manage other conditions of
the mouth such as mouth cancer, which may
be life threatening.
Awareness and diagnosis of oral cancer is
one of the primary responsibilities of any den-
tist, as the earlier the lesion is found the better
the outcome. A diagnosis of intraoral carci-
noma is primarily clinical but should always be
confirmed histologically; however, this should
not be undertaken in general dental practice
because a biopsy will alter the appearance of
the lesion and consequently makes it more
difficult for a hospital specialist to examine
and assess it. GDPs should immediately refer
a patient with a suspicious lesion to the local
oral and maxillofacial department.
The MDT are responsible for ensuring that
specialised dentistry is available for head and
neck cancer patients who require it. The British
Association of Head and Neck Oncologists’
recommend that every patient, not just those
planned for radiotherapy, should have a den-
tal assessment. Many of these patients have
complex needs which cannot be satisfactorily
met by the primary care dental services. It is
essential that expert dental care is provided
before, during and after radiotherapy.
It is important that dental practitioners have
an understanding not only of the effects of

BRITISH DENTAL JOURNAL VOLUME 218 NO. 2 JAN 23 2015 65

© 2015 Macmillan Publishers Limited. All rights reserved

 PRACTICE
malignant disease on their patient, but also
the specific problems and side-effects from the
cancer treatments. Patients undergoing radio-
therapy can experience several unwanted oral
side effects, which have both short- and long-
term implications. GDPs should be aware of
these implications and should liaise closely with
the restorative consultants and the oncology
team to establish the best oral care pathway.
THE SIDE-EFFECTS OF RADIOTHER-
APY ON THE ORAL ENVIRONMENT
Therapeutic radiation to the head and neck
causes both immediate sequelae such as
cellulitis, mucositis, dysphagia, dysguesia,
weight loss and severe pain of varying inten-
sities, as well as long term sequelae such
as rampant caries, trismus, xerostomia and
osteoradionecrosis.6,7
The effects are variable and often difficult
to predict. The effects are dose-related and
are significant above an absorbed dose of
60 Grays (Gy). Intensity-modulated radiation
therapy (IMRT) can help to reduce the side-
effects of radiation by producing a custom
tailored radiation dose that maximises dose
to the tumour while also minimising the dose
to adjacent normal tissues. IMRT allows for
the radiation dose to conform more precisely
to the 3D shape of the tumour by modulating
or controlling the intensity of the radiation
beam in multiple small volumes. IMRT also
allows higher radiation doses to be focused
to regions within the tumour while minimis-
ing the dose to surrounding normal critical
structures. Treatment is carefully planned by
using 3D computed tomography or magnetic
resonance images of the patient in conjunc-
tion with computerised dose calculations to
determine the dose intensity pattern that will
best conform to the tumour shape. The disad-
vantages of IMRT are apparent; it is not only
more complex to plan and deliver but is much
more costly. None the less, the advantages of
IMRT are such that it is increasingly used for
delivery of head and neck radiotherapy.
Mucositis
Mucositis is a particularly distressing and pain-
ful condition arising from damage to the oral
mucosal lining. It presents as a widespread oral
erythema, pain, bleeding and ulceration. Oral
mucositis is a common and often debilitating
complication of cancer treatment. The symp-
toms of mucositis may occur during the second
or third week of radiation therapy. The symp-
toms are common, temporary and gradually
subside within two or three weeks of complet-
ing treatment.
Xerostomia
Xerostomia is defined as a dry mouth resulting
from reduced or absent saliva flow. Xerostomia
66
Table 1 Clinical oral dryness score
1 Mirror sticks to buccal mucosa
2 Mirror sticks to tongue
3 Saliva frothy
4 No saliva pooling in the floor of the mouth
5 Tongue shows generalised shortened papillae
6 Altered gingival architecture (ie smooth)
7 Glassy appearance of oral mucosa especially
palate
8 Tongue lobulated/fissured
9 Cervical cavitations on more than two teeth
10 Debris on palate or sticking to teeth
is not a disease, but it may be a symptom of
various medical conditions, and is a side effect
of radiation to the head and neck (Fig. 1).
Xerostomia is accountable for the most com-
mon long-standing problems following oro-
facial radiotherapy. Salivary flow is reduced
from the first week of radiation treatment and
this may result in long-term or permanently
dry mouth. Xerostomia is particularly severe
when both parotid glands are in the radio-
therapy field.
The Challacombe Scale is a clinical oral dry-
ness score which was developed from research
conducted at King’s College London Dental
Institute and its purpose is to visually iden-
tify and quantify xerostomia. It uses a simple
numeric system which enables the clinician to
quantify the severity of the xerostomia and to
decide if the condition needs treatment or not.
The Challacombe Scale works as an addi-
tive score of one to ten, with one being the
least severe xerostomia and ten being the most
severe xerostomia (Table 1). Each of the ten
aspects observed scores one point, providing
Fig. 1 Xerostomia due to radiotherapy
BRITISH DENTAL JOURNAL VOLUME 218 NO. 2 JAN 23 2015
© 2015 Macmillan Publishers Limited. All rights reserved
a total score. Symptoms of xerostomia will not
necessarily progress in the order listed, but any
cumulative score higher than three is likely to
be a high-risk patient.
Recording the Challacombe for every patient
before, during and after radiotherapy is desir-
able as it can be a great benefit for both the
clinician and the patient
Currently the scale is being targeted at all
medical professionals who may have to diag-
nose xerostomia. This will include all members
of the dental team, GPs and practice nurses, all
care assistants and many more.
Radiation-associated caries
Caries has been seen as an important problem
in head and neck radiation patients for many
years (Fig. 2). It is well documented that ‘radia-
tion caries’ can start within three months of the
completion of radiation.7–9
Head and neck radiation therapy patients
are at high risk of developing caries due to
the amalgamation of permanent diminution of
saliva, high sugar consumption and the high
level of cariogenic flora.8
Oral candidal infections
Radiation induced xerostomia can result in
increased oral candida counts (thrush). This
may persist for several months after treatment,
thus increasing susceptibility to candidiasis,
particularly when dentures are worn.8
Loss or alteration of taste and
weight loss
Many head and neck oncology patients expe-
rience problems with swallowing either as a
result of surgery (for example, to the tongue
or pharynx) or as a result of fibrosis and scar-
ring secondary to radiotherapy. This can result
Fig. 2 Radiation-associated caries

in difficulties or an inability to eat certain
foods. A diet consisting of only fluids, pureed
or mashed foods may be required. This can
result in difficulties with gaining adequate
nutritional intake. Patients are subsequently
often prescribed high-sugar-containing food
supplements to aid in calorie intake and are
encouraged to add sugar and fats to foods
when possible.
Alteration of taste sensation occurs as a
result of the direct effect of radiation on taste
buds and due to changes in the saliva. This
ranges from the inability to taste (ageusia),
decreased ability to taste (hypogeusia) or dis-
torted taste (dysgeusia). Dysgeusia occurs rap-
idly and exponentially up to 30 Gy, after this
taste diminishes at a slower rate until reaching
ageusia. Taste acuity is partially restored in
20–60 days after the completion of radiation
and in most patients is restored almost com-
pletely within four months.10 However, some
patients may experience life-long alteration or
loss of taste.10 Dysgeusia or ageusia generally
causes malaise in patients as they quickly lose
interest in food, which may lead to compro-
mised nutritional status and weight loss.
Trismus
Trismus occurs as a side effect of radiotherapy,
especially in cases where the tumour invades
the muscles of mastication and in cases requir-
ing surgical intervention. Surgery may induce
scar tissue which reduces mouth opening due to
scar contraction in the muscles of mastication
(Fig. 3). Additionally, radiotherapy may induce
fibrosis in these muscles as a late radiation
effect.11–13 Seventy-eight percent of patients
experience severe difficulties in mastication
following major head and neck surgery with
implications for normal social adaptation.14
Fig. 3 Trismus – Patient shown is at
maximal opening
Fig. 4 Osteoradionecrosis (ORN)
BRITISH DENTAL JOURNAL VOLUME 218 NO. 2 JAN 23 2015
The most decisive factor in whether trismus
develops or not is probably the inclusion of
the medial pterygoid muscles in the treatment
portals.13 There is some evidence that osteora-
dionecrosis and trismus risk may be genetically
determined by alleles of the TGFß1 gene.15
Osteoradionecrosis
Osteoradionecrosis (ORN) is a potential long
term and arguably the most serious side effect
of radiotherapy (Fig. 4). The definition of
osteoradionecrosis is an area of exposed devi-
talised irradiated bone that fails to heal over
a period of three to six months in the absence
of local neoplastic disease.16–20
Early presentation of ORN, within two years,
is thought to be related to high doses of radi-
otherapy (>70 Gy) whereas late presentation
is usually secondary to trauma and delayed
wound healing within compromised tissue.21
Tooth extraction has been considered one of
the main risk factors for the development of
ORN. The incidence of ORN varies widely in
the literature ranging from 1–37%.22 The exact
incidence of ORN after post-irradiation extrac-
tion is unknown. In general the data showed
a downward trend of the risk of developing
ORN after extractions in recent years. The inci-
dence of ORN after post-irradiation extractions
performed after 1990 was 2%, compared with
16% before then.21 The risk of post-extraction
ORN is widely reported to be greater for the
mandible compared with the maxilla.21 The
pattern of blood supply to the mandible has
been implicated as a primary reason for this
finding.25 Other more simple explanations
claim that the mandible is included in the
radiation field more often than the maxilla.
Patients are at particular risk of ORN when:26
• The total radiation dose exceeded 60 Gy
• The dose fraction was large with a high
number of fractions
• There is local trauma as the result of a
tooth extraction, uncontrolled periodontal
disease or an ill-fitting prosthesis
• The patient is immune-deficient
• The patient is malnourished
• Proximity of tumour to bone27
• Primary site of tumour. Posterior mandible
is more commonly affected by ORN
because of its compact and dense nature28
• State of dentition – odontogenic and
periodontal disease29
• Poor oral hygiene29
THE ORAL MANAGEMENT OF
ONCOLOGY PATIENTS BEFORE
RADIOTHERAPY
It is imperative that certain head and neck can-
cer patients have a pre-radiotherapy assessment
before the commencement of any radiotherapy
treatment. The pre-radiotherapy assessment
must include a radiographic survey for dentate
© 2015 Macmillan Publishers Limited. All rights reserved
PRACTICE
patients and careful clinical assessment of any
prosthesis worn by the patient.6 The aim of
the pre-radiotherapy dental assessment is to
maximise the patients quality of life following
oncological treatment. Maximising quality of
life may involve retaining teeth for function,
aesthetics and speech. Conversely, multiple pre-
radiotherapy extractions may be more appropri-
ate to avoid the complication of ORN developing
from extracting teeth post-radiotherapy. Where
IMRT is to be used, it is essential to arrange the
assessment and management of the patient as
swiftly as possible to allow the oncologist the
maximum time to plan the therapy.
Oral hygiene instruction
The importance of general dental care and oral
hygiene, especially for head and neck cancer
patients, cannot be over emphasised and a pro-
active preventative/preventive treatment plan
is mandatory. In order to resolve any gingivitis
and to maintain a relatively plaque free mouth,
dentate patients should use 10 ml of chlorhex-
idine gluconate mouth rinse at a concentra-
tion of 0.2% (Corsodyl) twice daily for a week
before radiotherapy and chemotherapy.30,31
Which teeth to extract and timing
of extractions
Dental extractions in the field of radiation
put patients at risk of ORN and consequently
it is advisable to extract teeth with a poor
long-term prognosis that will be within the
radiotherapy field. All viable teeth should be
retained for aesthetics and functional needs,
denture stability and maintain quality of
life. The less motivated the patient, the more
aggressive one should be in extracting teeth
before radiotherapy.
It is generally agreed that teeth with a poor
prognosis must be extracted before radiother-
apy.32 This includes:
• Advanced caries lesions with questionable
pulpal status or pulpal involvement
• Extensive periapical lesions
• Moderate or advanced periodontal disease
(extensive attachment loss), especially
with advanced bone loss and mobility or
furcation involvement
• Residual root tip if not fully covered by
alveolar bone or showing radiolucency
• Impacted or incompletely erupted teeth,
particularly third molars that are not fully
covered by alveolar bone or that are in
contact with the oral environment.16,32,33
The extractions should be performed as
atraumatically as possible and with primary
closure.34
Ideally, any extractions should be done as
soon as possible before radiotherapy starts,
however, this is not always practicable due
to time constraints. Preferably the extrac-
tion should be undertaken up to three weeks
67
 PRACTICE
before commencement of radiotherapy. If
this is not possible then the minimum heal-
ing time for the socket before radiotherapy is
ten days for maxillary teeth and one week for
mandibular teeth.30,31
Restorative treatment
The effects of irradiation and chemotherapy
make the soft tissues very susceptible to
trauma. It is therefore important to make sure
that all irregular teeth and sharp areas on res-
torations are smoothed down and dentures
suitably adjusted to avoid irritation.6 Where
time permits it is preferable to restore teeth
with a permanent restorative material.
The maximum mouth opening (inter-arch
or inter-incisal distance) should be measured
before radiotherapy is started, and the patient
and/or clinician should measure this distance
frequently thereafter to ensure it is maintained
(Fig. 5). However, growth of the tumour can
sometimes restrict mouth opening even before
radiotherapy is commenced.
Appliance wear
When maxillary surgery is to be combined
with radiotherapy, an obturator may be an
option for rehabilitation of the maxillary defect
and this would need to be planned in liaison
with the surgical team. Applicator trays may
be constructed for dentate or partially den-
tate patients for fluoride or chlorhexidine gel
delivery later in the management process.6 An
assessment of the patients existing dentures
should be made to ensure that it is not going
to cause trauma to the mucosa during radio-
therapy. In reality, the majority of patients may
stop wearing their dentures during treatment
and therefore advice may be required on over-
coming potential difficulties when returning to
wear the prosthesis.
Fig. 5 Therabite measurer
68
SUMMARY
Head and neck radiotherapy may result in
multiple unpleasant early and late oral side
effects, which can impact on general wellbeing
and quality of life. Prevention or reduction of
these side effects are a matter of increasing
importance especially because of the increase
in aged and dentate head and neck cancer
patients. It is imperative that certain head and
neck cancer patients have a pre-radiother-
apy dental assessment to help maximise the
patient’s quality of life following oncological
treatment. Additionally the medical complex-
ity of these patients affects dental treatment
planning, prioritisation, and timing of den-
tal care and such patients require significant
support from the dental team before, during
and after radiotherapy. The patient’s GDP, in
communication with the restorative consult-
ant on the oncology core team, can deliver
much of the advice and treatment required. A
planned team approach is the most effective
way to maintain the oral and dental health of
this vulnerable patient group and can also help
to minimise some of the inconveniences that
these patients face (for example, travel to the
core team and the delay that this incurs) and
ultimately improve their quality of life.
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