Radiotherapy

Implications for dentistry

Adapted from source

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 Surgery
 Cytotoxic chemotherapy
 Radiotherapy
 Effects of radiotherapy on oral structures and
management of those effects

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 Cure – eradication of all cancer
 Benefit – long term survival
 Some long term side effects are acceptable
 Palliation – alleviate effects of cancer
 eg relieve pain, shrink cancer with chemotherapy
 Benefit - modest
 Side effects of treatment should be slight

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 Oral Cavity 1970-2005 : Overall stage
100
90
85% (461-234) S1
80
75% (575-249) S2
70
67% (2142-777) All
% SURVIVAL

60 65% (346-122) S3
50
45% (701-157) S4
40
30
20
10
0
12 24 36 48 60
MONTHS
95% CI Median
S1 461 419 363 316 267 234 [ 82, 88 ]
S2 575 502 427 361 308 249 [ 72, 79 ]
All 2142 1673 1326 1108 935 777 [ 64, 68 ]
S3l 346 266 211 175 147 122 [ 59, 70 ]
S4l 701 440 289 227 191 157 [ 40, 49 ] 36 Mths
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 Anticancer drugs given by iv injection as a course,
either weekly or every 3 weeks over about 4 months
 Acute effects
 Nausea, vomiting
 Mucositis, mouth and lip ulcers
 Bone marrow suppression – thrombocytopenia, neutropenia
(may be severe), hence increased risk of infection
 Late effects uncommon except after leukemia chemo
 Used to treat cancers of breast, bowel, lung, lymphoma,
head and neck
 If an invasive dental procedure is needed during
chemotherapy check FBC and discuss with the
oncology team

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 X-rays are part of the electromagnetic spectrum
beyond UV
 Low dose used for diagnostic x-rays
 Very high dose radiation produces tissue
effects
 Radiotherapy uses very high energy x-rays to
very high dose (shielding treatment room 1m
thick concrete)

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 Treatment machine – linear accelerator
 May use multiple beams of various shapes
 RT course – daily, 5 days per week for 6-7
weeks
 Sometimes cytotoxic chemotherapy is added,
concurrent with radiotherapy, does increase
cure rates but increased toxicity

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 Can cover a wider volume than surgery
 For head and neck cancer, RT is used as an
alternative to surgery or as supplementary
treatment with surgery
 where surgery would produce functional defect, eg
early larynx tumours, nasopharynx, posterior tongue
 where surgery unlikely to be curative
 where surgery likely to leave microscopic disease
 Oral cancer – surgery preferred to RT

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 Design radiation target volume to cover
primary plus regional nodes
 Design dose radiation according to bulk of
tumour at various sites.
 eg macroscopic disease - high dose,
 microscopic disease - lower dose
 If a well lateral tumour then design
radiotherapy volume to treat unilateral
structures avoiding high dose to contralateral
structures
 Fractionation of radiotherapy – multiple
smaller fractions gives less late side effects than
shorter courses

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PTV 60Gy PTV 70Gy

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 Loss of taste
 Xerostomia
 Mucositis
 Oral thrush

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 Hyposalivation – xerostomia.
 Lack of taste
 Atrophy mucosa
 Atrophy of alveolus – delay fitting dentures
until 6-12 months after RT
 Dental caries, may be severe
 Osteoradionecrosis of the mandible
 Trismus

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 Hyposalivation - decreased saliva. Sometimes
symptoms of xerostomia improve a little over
time.
 Increased viscosity
 Acid saliva, from the normal pH 7 down to pH
5
 Altered oral flora with increase acidogenic and
cariogenic organisms (Streptococcus mutans,
Lactobaccillus, Candida)
 Altered electrolytes, effect remineralisation of
dentine
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 Fluids frequent sips of water
 Artificial saliva – based on
carboxymethylcellulose or mucin
 Bicarbonate mouth washes
 Neutral chewing gum
 Treat oral thrush
 Antiseptic mouth washes to treat infective
organisms
 Pilocarpine – limited benefit

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 Hypersensitivity of teeth initially
 Decreased remineralisation
 Increased caries, which may be severe, rapid
onset, painless
 Caries may have a different pattern to usual, on
labial surfaces at dentin-enamel junction, and
may include mandibular anterior teeth
 Black brown discoloration of entire tooth
crown
 Dentin microhardness effected, enamel chips
break off

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 Maxillofacial surgeon assessment prior to radiotherapy
 Poor teeth extracted prior to RT
 Good teeth preserved in moderate dose region
 Molars in the high radiation dose region may be
extracted with alveoplasty and healing prior to RT

 Neutral tooth paste

 Bicarbonate mouth washes
 Chlorhexidine mouth wash
 Fluoride gel applications daily to help mineralisation
long term
 Frequent dental assessment

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 Osteoradionecrosis of mandible
 Factors
 high radiation dose
 trauma
 infection
 Avoid trauma to area of mandible that has
received very high radiation dose
 Get information on radiation dose prior to dental
extraction

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 High activity bisphosphonates
 Zoldronate
 Pamidronate
 Above drugs mainly used for myeloma and breast
cancer
 Sclerosis of bone
 Trauma may precipitate osteonecrosis
 Minor – small area of ulceration of mucosa over
alveolus with exposure of superficial mandible.
Sometimes small spicules of bone can be extruded.
 Avoid trauma eg from dentures rubbing mandible
 Treat any sharp areas causing abrasion
 Tetracycline
 Hyperbaric oxygen
 Major – deep area of necrosis, infection
 This is a major problem, difficult to treat
 Management by a Maxillofacial surgeon
 Drain abscess
 Debride necrotic tissue (caution: trauma can exacerbate
osteoradionecrosis)
 High dose broad spectrum antibiotics (infectious disease
specialist)
 Hyperbaric oxygen

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 Results of treatment of head and neck cancer
usually good
 Chemotherapy effects are acute
 Radiotherapy important treatment method
 Radiotherapy to mouth has significant long
term side effects on saliva, teeth and mandible
 As the results of treatment improve, it is
possible more dentists will come in contact
with patients who are having chemotherapy or
who have previously had radiotherapy

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 Kielbassa AJ et al. Radiation-related damage to
dentition.
Lancet Oncology 2006;7:326-35.

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