IONIZING RADIATION AND ITS

EFFECTS ON ORAL TISSUES

DR HASSAAN UL QAMAR
Learning Outcomes

By the end of this lecture, students will be able to know:

 What is Ionizing radiation
 What are its uses in dentistry
 What are its effects on oral tissues
 How to manage its effects on oral tissues
 Dental management of patients receiving radiotherapy of the head and neck
What is Ionizing Radiation?
 Energy emitted from a source is generally referred to as radiation. Examples
include heat or light from the sun, microwaves from an oven, X rays from an X-
ray tube, and gamma rays from radioactive elements.

 Ionizing radiation is radiation with enough energy so that during an interaction

with an atom, it can remove tightly bound electrons from the orbit of an atom,
causing the atom to become charged or ionized.

Here we are concerned with only one type of radiation, ionizing radiation, which
includes Alpha particles, Beta particles, X-rays, Gamma rays
Clinical applications of Ionizing Radiation in
Dentistry
Ionizing Radiation has two different uses in Dentistry:
1. Diagnostic and
2. Therapeutic

 X-RAYS:
1. Routine examination
2. Diagnostic purpose
3. Treatment planning and follow-up examination of patients
 Much higher doses are required for treatment of Malignant diseases in
combination of other forms of treatment.
Effects of Ionizing Radiation on Oral tissues

 Radiotherapy damages only cells undergoing mitosis – such as Epithelium

 Adverse effects may arise immediately and are predictable i.e.
1. Taste loss
2. Mucositis
3. Hyposalivation

 Others appear later and may include:

1. Radiation caries
2. Jaw osteoradionecrosis
Mucositis

 Inflammation of Mucosa
 Typically begins at doses of 15Gy (after around 10 days), reaches full severity at
30Gy, persisting for weeks or months
 Most susceptible sites:
1. Soft palate,
2. Lateral borders of tongue,
3. Ventral surface of the tongue,
4. Floor of the mouth
(Tissues which have a good vascular supply and a higher cell turnover)
 Risk factors apart from Radiotherapy:
1. Concurrent Chemotherapy
2. Younger age
3. Alcohol
4. Poor oral hygiene
5. Dental disease

 Can be reduced by
1. Minimizing doses and field of radiation
2. Using mucosa-sparing blocks
3. Using amifostine before therapy
4. Avoiding chemo-radiotherapy
5. Betamethasone mouthwashes
 Healing: depends on radiation dose, Is usually complete within 3 weeks after the
end of treatment. Tobacco smoking delays healing.

 Treatment:
1. Opioids, such as Morphine and Hydromorphone
2. Avoiding irritants (smoking, spirits, spicy foods)
3. Good oral hygiene
4. Topical analgesics, prior to meals, helps combat pain and dysphagia. Such as
Benzydamine hydrochloride, 2% lidocaine mouthwash, Aspirin
Hyposalivation
Changes may be:
 Quantitative (dry mouth or hyposalivation)
 Qualitative (pH falls, buffering capacity decreases, electrolytes change)

Factors predisposing to salivary changes:

 Radiation
 Dose
 Number of exposures
 Type
 Salivary gland
 Function before Radiotherapy
 Volume irradiated

Hyposalivation can be reduced by:

 Minimizing doses and field of radiation
 Using parotid-sparing tech such as IMRT (Intensity Modulated Radiotherapy)
 Using amifostine or pilocarpine before therapy
 Avoiding chemo-radio

MANAGEMENT:
 Saliva substitutes, frequent ice cubes, popsicles, sips of water, Sialogogues, e.g.
pilocarpine or cevimeline
Loss of taste (Hypogeusia)

 follows radiation damage to the taste buds.

 Taste may start to recover within 2–4 months and is typically restored by 6
months
 If more than 6000Gy have been given, loss of taste may be permanent.

MANAGEMENT:
 Consider zinc sulphate
Radiation caries

 Patients frequently take a softer, more cariogenic diet because of mouth dryness
and soreness, and loss of taste.
 Salivary protection is diminished. There is a change to a more cariogenic oral
flora and the hypersensitive teeth make oral hygiene difficult.
 These factors combine to cause rampant dental caries, including in areas such as
incisal edges and cervical margins, which are normally free from caries.
 Begins between 2 and 10 months after radiotherapy, complete dentition may be
destroyed within a year of irradiation.
 May be minimized by:
1. controlling sugar intake,
2. protecting salivary function as above, and
3. using fluorides (toothpastes or topical applications), sialogogues and mouth-
wetting agents
Candidosis
 Factors responsible:
1. Hyposalivation
2. Treatment-related immunosuppression
3. Frequent use of antibiotics
4. Diet – frequent consumption of fermentable Carbohydrates
5. Wearing of Dental prosthesis or Obturators
 Prevention:
1. Oral hygiene instruction
2. Professional tooth cleaning
3. Prosthesis and other reconstructive structures must be kept clean by brushing at least twice daily
(Chlorhexidine or commercial cleaning preparations are also recommended)
4. Antifungal agents (for recurrent infections) for one week every 2-6 weeks
5. Mouth wetting agents

 Treatment:
1. Infection verified by culture samples
2. Systemic antifungals avoided, because of potential selection of resistant strains
3. Topical antifungals are first choice treatment (e.g. Nystatin, Miconazole) for 5-6 weeks
4. Alternatively, or in addition, non-alcoholic containing Chlorhexidine mouth rinses twice daily for two
weeks
Sialadenitis
 May follow irradiation and cytostatic drugs (inhibit growth and cell division)
 May lead to irreversible hyposalivation
 Renders cancer patients liable to ascending bacterial sialedinitis
 Mainly involving Staph. aureus, Strep. viridans (often penicillin-resistant), ascending
from the oral cavity

Management:
 Hospitalization
 Analgesia, amoxicillin
 Flucloxacillin or amoxicillin/clavulanate if staph and not allergic to penicillin
 Erythromycin or Azithromycin, in penicillin allergy
 Surgical drainage if fluctuation is there
 Chewing gums or sialogogues for salivary stimulation
Trismus
Cause: reduced vascularity from Endarteritis obliterans following radiotherapy
 Leads to fibrosis in the muscles of mastication
 May also results from Scar tissue from surgery, nerve damage, tumor infilterarion
 Tumors related: Nasopharyngeal, base of tongue, salivary gland and cancers of maxilla or
mandible
 Most likely if Radiation in excess of 60Gy and when the patient has been previously
irradiated
 May begin toward the end of radiotherapy or during the subsequent 12 months, tends to
increase slowly over several weeks or months

Management:
 Jaw-opening exercises three times daily
Osteoradionecrosis (ORN)
 Most serious complication
 Follows endarteritis obliterans from Radiotherapy in high doses involving the oral
cavity, maxilla, mandible and salivary glands
 Defined as “exposed irradiated bone that fails to heal over a period of 3
months without a residual or recurrent tumour”

AETIOLOGY AND PATHOGENESIS

 Mandible (high density, poor vascularity) > Maxilla
 Great risk if: radiation dose > 60 Gy, 10 days before to several years after
radiotherapy, maximal at 3-12 months, in malnourished or immunocompromised
 Initiating factor: Trauma, such as tooth extraction, oral infection, ulceration
from a dental appliance
 Pathogenesis is not completely understood
 Appears in hypoxic, hypovascular, hypocellular tissue, where there is tissue breakdown
leading to a non-healing wound

Risk factors:
 Radiation related: Total dose, photon energy, brachytherapy, field size.
With IMRT, only small volumes of the jaw are exposed to high radiation doses, so this may
reduce chances of ORN
 Trauma and surgery: increased risk if tooth extractions are performed after Radiotherapy but
little risk if extractions are performed before
 Drug use: Alcohol and tobacco increase risk. Corticosteroids and anticoagulants used
before or after Radiotherapy redeuce the risk
 Genetic: presence of T variant allele within the TGF-Beta1 gene
TREATMENT:
 Long-term antimicrobials, esp. Tetracycline (high bone penetrance)
 Local cleansing
 Conservative management, avoid additional jaw surgery
 Pentoxyfyline (PTX), for 6 months or Pentoxyfyline+Vit E accelerates healing

PREVENTION:
 Extractions of all decayed and periodontally compromised teeth before jaw Radiotherapy
 Teeth within the high-dose field that are unrestorable or have advanced periodontal
involvement. Only such teeth need to be extracted.
 Patients who required Multiple extractions or extensive surgical extractions, or both, can be
given 8 weeks of PTX 400mg twice daily with tocopherol, starting a week before the
procedure, as prophylaxis
Other effects

 ONCOGENESIS: Irradiation for retinoblastoma can lead to development of jaw

osteosarcoma

 DISTURBED DEVELOPMENT: Maldevelopment of jaws and teeth in children

 CAROTID ARTERIOSCLEROSIS: Radiotherapy can accelerate or initiate this

Dental mamagement of patient receiving
radiotherapy to the head and neck
Before Radiotherapy:
 Meticulous oral hygiene should be implemented, preventive dental care instituted
and restorative procedures carried out.
 Unsalvageable teeth in the radiation path should be extracted at least 2 weeks
before starting radiotherapy and no bone should be left exposed in the mouth.
During Radiotherapy:
 amifostine can minimize mucositis and hyposalivation.
 Smoking and alcohol should be discouraged.
 Mucositis may be relieved by using warm normal saline mouthwashes and benzydamine oral
rinses or lidocaine 2% gel.
 A 0.2% chlorhexidine mouthwash improves oral hygiene.
 Antifungal drugs, such as nystatin suspension as a mouthwash used four times daily.
 Trismus may be improved by jaw-opening exercises with tongue spatulas, wedges or
TheraBite®, used three times a day.
AFTER RADIOTHERAPY:
 Oral hygiene and preventive dental care should be continued.
 Radiation caries and dental hypersensitivity can be controlled with a non-cariogenic
diet, high-fluoride dentifrice and daily topical fluoride applications, such as fluoride
mouthwash.
 If extractions become unavoidable, trauma should be kept to a minimum, raising the
periosteum as little as possible, ensuring that sharp bone edges are removed, suturing
carefully and giving prophylactic antibiotics in adequate doses from 48 hours
preoperatively, continued for at least 4 weeks to prevent ORN. Clindamycin 600mg
three times daily is an appropriate antibiotic since it penetrates bone well.
 If dentures are required, they should be fitted at about 4–6 weeks after radiotherapy,
when initial mucositis subsides and there is only early fibrosis.