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 ² eradication of all cancer ƒ Benefit ² long term survival ƒ Some long term side effects are acceptable Palliation ² alleviate effects of cancer ƒ eg relieve pain, shrink cancer with chemotherapy ƒ Benefit - modest ƒ Side effects of treatment should be slight

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Oral Cavity 1970-2005 : Overall stage
100 90 80 70
% SURVIVAL

85% (461-234) S1 75% (575-249) S2 67% (2142-777) All 65% (346-122) S3 45% (701-157) S4

60 50 40 30 20 10 0 12 419 502 1673 266 440 24 MONTHS 363 427 1326 211 289 36 316 361 1108 175 227 48 267 308 935 147 191

60 234 249 777 122 157 [ [ [ [ [ 95% CI 82, 88 72, 79 64, 68 59, 70 40, 49 Median ] ] ] ] ]

S1 S2 All S3l S4l

461 575 2142 346 701

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
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Nausea, vomiting Mucositis, mouth and lip ulcers Bone marrow suppression ² thrombocytopenia, neutropenia (may be severe), hence increased risk of infection

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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 ² linear accelerator May use multiple beams of various shapes RT course ² 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 ƒ where surgery unlikely to be curative ƒ where surgery likely to leave microscopic disease
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Oral cancer ² 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.
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eg macroscopic disease - high dose, ƒ microscopic disease - lower dose

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If a well lateral tumour then design radiotherapy volume to treat unilateral structures avoiding high dose to contralateral structures Fractionation of radiotherapy ² 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 ² xerostomia. Lack of taste Atrophy mucosa Atrophy of alveolus ² 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 ² based on carboxymethylcellulose or mucin Bicarbonate mouth washes Neutral chewing gum Treat oral thrush Antiseptic mouth washes to treat infective organisms Pilocarpine ² 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 ƒ high radiation dose ƒ trauma ƒ 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 ƒ Zoldronate ƒ Pamidronate Above drugs mainly used for myeloma and breast cancer Sclerosis of bone Trauma may precipitate osteonecrosis

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Minor ² small area of ulceration of mucosa over alveolus with exposure of superficial mandible. Sometimes small spicules of bone can be extruded.
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Avoid trauma eg from dentures rubbing mandible Treat any sharp areas causing abrasion Tetracycline Hyperbaric oxygen 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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Major ² deep area of necrosis, infection
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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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