THE RADIATION

THERAPY PATIENT-
TREATMENT PLANNING
,POST TREATMENT CARE
BY
VYOMA G V
3rd MDS
1
CONTENT
• INTRODUCTION
• INDICATIONS OF RADIATION THERAPY
• PRINCIPLES OF RADIATION THERAPY
• TREATMENT PLANNING FOR RADIATION THERAPY
• USE OF PROSTHETIC SPLINTS FOR RADIATION THERAPY
• RADIATION EFFECTS ON ORAL CAVITY
• DENTAL MANAGEMENT OF DENTULOUS RADIATION THERAPY PATIENTS
• DENTAL MANAGEMENT OF EDENTULOUS RADIATION THERAPY PATIENTS
• PROSTHODONTIC MEASURES IN PATIENTS UNDERGOING RADIATION THERAPY -
IN DETAIL
• CONCLUSION
• REFERENCES

2
 INTRODUCTION

RADIATION – the emission of electromagnetic waves like light, short wave, radio, UV or X-rays or
particulate rays such as alpha, beta, gamma - GPT-9

• Radiation therapy has been used with increasing frequency in recent

years in the management of neoplasms of the head and neck region.
• A majority of patients with such tumors will receive radiotherapy at
some time during the course of their disease.
• In some tumours it is preferred treatment, where as in others it is
employed in combination with , surgery or sometimes with
chemotherapy – less doses.

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 INDICATIONS OF RADIOTHERAPY
 Squamous cell carcinomas of soft palate, floor of mouth, tongue, lips,and buccal mucosa
 Adenocarcinomas of salivary and mucous glands
 Primary lymphomas nasopharynx, tonsils
 Carcinomas of maxilla and mandible , piriform sinus , subglottic area etc.

HIGHLY MODERATELY RADIO

SENSITIVE TUMORS
SENSITIVE SENSITIVE RESISTANT
• Germ cell • Tumors of reticuloendothelial origin • Squamous cell • Malignant
neoplasms • Hodgkin's lymphoma Lymphosarcoma carcinoma melanoma
• Dysgerminomas • Reticulum sarcoma • Basal cell • Osteogenic
• Seninomas • Gaint follicular lymphoma carcinoma sarcoma
• Leukemic • Lymphoma cutis • Adenocarcinom • Adenocarcinom
infiltrates a of uterus and a (other than
• Multiple myeloma
breast breast or
• Tumors of nervous system uterus)
• Neuroblastoma • Teratoma
• Medulloblastoma
• Retinoblastoma
Maxillofacial Prosthetics : Multidisciplinary Practice – Chalian, Drane & Standish
4
 RADIATION THERAPY OF HEAD AND
NECK TUMORS

PHYSICAL PRINCIPLES

ABSORPTION OF RADIATION BY TISSUES

BIOLOGIC EFFECTS

DOSIMETRY

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 PHYSICAL PRINCIPLES
the therapeutic use of ionizing radiation in the management of neoplasms without surgery or as an
adjunctive palliative treatment after surgery, either in combination with or with out chemotherapy”

• Electromagnetic waves of wave lengths less than 1

angstrom are called photons
ELECTROMAGNETIC • By definition, photons that have an energy superior or
WAVES equal to 1 MeV are called high energy photons
• X- rays- machines and electric devices and Gamma rays
– radioactive disintegration

• Particulate radiations, which have mass, are charged

PARTICULATE negatively (electrons, pi-mesons), positively (protons, alpha
RADIATION particles), or are neutral (neutrons).
• Treats deep seated tumours

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 ABSORPTION OF RADIATION BY TISSUES

BY THE BY THE
BY PAIR
PHOTOELECTRIC COMPTON
PRODUCTION
EFFECT EFFECT

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 In particulate radiation – particles carrying an electric charge

 Absorbed in tissues by colliding with the orbital electrons of atoms

 Neutrons- no charge; absorbed by colliding with hydrogen nuclei- similar

mass- most numerous in tissues;

 IONIZATION- secondary protons that are set in motion by the incident

neutrons

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 BIOLOGIC EFFECTS
• The primary effects of radiation occur within the nucleus, since
it is 100 to 1000 times more sensitive to radiation than the
cytoplasm.

• Few cells die – direct effect

• Damage –intranuclear –DNA and the mitotic apparatus

• Damage to these structures may be lethal (irreparable) or

sublethal, and may not be apparent until at least 1 cellular
division is attempted

• repair time will vary with different tissues, a minimum safe

clinical interval of 6 hours is necessary. This process is known as
REPAIR OF SUBLETHAL DAMAGE

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 DIRECT INDIRECT
DAMAGE DAMAGE

Direct action results when

secondary particles (i.e.,
recoil electrons and
protons) interact with the
target
molecule

 In radiation biology, the target molecule is the DNA; However, DNA molecules are relatively
scarce as compared to the surrounding molecules of water.
 INDIRECT action – higher probability of causing damage

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 • biologic actions on target tissues are dependent on the level of
oxygenation

• Anoxia – 3x more resistant to radiation effect

• REOXYGENATION

• Heavy particles- neutrons – LINEAR ENERGY TRANSFER –

overkill

• Effect on individual cells – position – G1 AND M- most vulnerable

• Cell populations – asynchronous – synchrony – REDISTRIBUTION

of cells within the cell cycle

• REPOPULATION This means that, given enough overall treatment

time,-cells in irradiated tissue can proliferate and repopulate

• cytotoxic agent, including radiation, can trigger clonogenic

surviving cells in a tumor to divide faster than before -
ACCELERATED REPOPULATION - 4 weeks

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 • FRACTIONATION - Radiation therapy is delivered in a series of
treatments or fractions. Most – external curative therapy for oral tumors in about 30
fractions spread over a 6-7 week period.

1st FRACTIONATED RADIATION -

REOXYGENATION

2ND FRACTIONATED RADIATION – Increased

chance to affect most tumor cells in
RADIOSENSITIVE phase of cells

3rd – Normal cells recover better from sublethal

damage than tumor cells between fractions

4th - enhances therapeutic ratios and ensures it works

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 • ALTERED FRACTIONATION-To improve the therapeutic ratio by maximizing
the tumour killing effect & minimizing acute & late toxicities

HYPERFRACTIONATION ACCELERATED FRACTIONATION

There is an increased total dose, accelerated fractionation offers a

total number of fractions, and number
of fractions per day, while decreasing
the
dose per fraction and keeping the
overall treatment time relativey
unchanged.
decreased overall treatment time and a
slight decrease in dose per fraction, while
increasing the number of fractions per day
and keeping the overall dose the same or
slightly decreased. The dose per fraction
is typically 140 to 160 cGy and given twice
or thrice daily

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 DOSIMETRY
• Purpose – to evaluate the amount of energy
absorbed by the tissues subjected to radiation
• Dosimeter is a device used to calculate the
amount of dosage required for a lesion
• RAD ((RADIATION ABSORBED DOSE) It is a
unit to measure the amount of energy absorbed
by tissues
• The standard unit of the absorbed dose is the
gray, which is defined as The depth dose curves are visualized on
a plane running along the axis of the
• “the energy absorption of 1 joule per kilogram of beam where the points of equal dose are
tissue.” This has replaced the rad, which connected, yielding curves known as
corresponds to an energy absorption of 100 isodose curves
ergs/gm. Therefore, 1 rad = 1 centigray
Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
14

ISODOSE CURVES: PHOTONS
SINGLE BEAM - When MULTIPLE BEAMS -When a tumor
radiation penetrates the is located deep, it becomes
tissues, dose decreases necessary to use 2 or more beams
from surface to the (radiation ports) in order to deliver a
depth dose to the tumor equal to or higher
than the dose
delivered to normal tissues
ISODOSE CURVES:
PARTICULATE RADIATION
• the electron beam - a rapid falling off of
the dose beyond the 80% to 90% isodose
line - permits treatment of superficial
structures like lymph node bearing
areas, yet spares deeper structures
• as the energy ,the depth to Dmax and
a dose is deposited- skin, so less skin
sparing.
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NOMINAL • As the dose increases , tissue changes become
SINGLE DOSE more profound and irreversible , leading to an
INDEX increased incidence of bone complications

• NOMINAL SINGLE DOSE index may be a

valuable predictor of tissue response- variables of
delivery indicate more accurately the true biologic
response

• Theoretically, normal tissue tolerance in head and

neck region – 1800 rad therapeutic equivalents

• Osteoradionecrosis occurring at levels lower than

1800rets is seen

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TO SUMMARIZE…

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TREATMENT
PLANNING FOR
RADIATION
THERAPY

18
To intiate the therapeutic irradiation, physician must first determine the tumor volume to be treated. By physical
examination; lab studies; radiographs; scans; bone marrow biopsy. Presuming possible subclinical involvement.

Risk and site involved are also assessed MAXIMUM

PERMISSIBLE DOSE IS CALCULATED

If some of the normal tissues cannot be spared- the dose the tissues
will receive has to remain below their threshold of radioimpairment.

Highly individualized technique

for each patient is developed

Port films are taken to verifythe radiation field, and ink marks or fixed
tattoos are placed on the patient’s skin to facilitate reproducibility.

Closely
monitored

Port films to monitor

accuracy and reproducibility

reevaluation

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Modalities available – implantation; external beam therapy
EXTERNAL RADIATION
THERAPY
• 3 categories- low energy x ray,
orthovoltage, high energy photon
• Electron beam therapy – high doses of
radiation to tumors within 6 cm;
• energy adjusted to the depth of the
tumor.
• Permitting the therapist to concentrate
the dose to this tumor volume while
sparing possible critical underlying
structures.
INTERSTITIAL RADIATION
THERAPY
• Short distance – rapid increase in dose –
INVERSE SQUARE LAW
• Radiation source may be placed in a
cavity – intracavitary; inserted directly
into the tissue – interstitial
• After the prescribed period – removed
• Needles, narrow tubes, wires, small
seeds
• Common radioactive material – radium/
artificial cesium, cobalt, gold, iridium
• Direct implantation – successful but
superceded by afterloading technique-
flexible and accurate –iridium 192
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GENERAL TISSUE EFFECTS

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 USE OF PROSTHODONTIC
STENTS AND SPLINTS
DURING THERAPY
Prosthetic devices (frequently called stents, splints, shields, carriers, or
positioners) can be used to optimize the delivery of radiation while
reducing the associated morbidity

RADIATION SHEILD - an intraoral device designed to shield adjacent tissues from radiation during
orthovoltage treatment of malignant lesions of head and neck – GPT-9

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 • Heat cure acrylic resin for fabrication of stent

MATERIAL • The alloys used for shielding are Cerroband, and

Lipowitz. Cerrobend (Cerrosafe, Cerrolow, Cerrotru)
USED is the most commonly used shielding alloy, which is
a low fusing alloy (158F / 70C) composed of
bismuth50% lead-26.7%, tin-13.3%, cadmium-10%

• preferred than lead- because of its melting

temperature- it can be melted and poured into the
cavity prepared, block out with clay and back scatter
prevented by autopolymerizing MMA resin, where
as lead has high melting point (600F)

• 1cm thickness of lipowitz alloy will effectively reduce

an 18MeV electron beam by approximately 95%

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Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd
edition. 1996
 Position
maintaining device
Perioral cone
POSITIONING positioning devise
STENTS Dosimeter
positioning device
Intraoral
positioning device
for stereotactic
PRE radiotherapy
RADIATION LOAD
CARRIERS AFTER Shielding
RADIATION LOAD
PROTECTING/ stent
STENTS SHEILDING Tongue depressing
STENTS stent
Displacing stent
Custom mouth protector

Bolus
OTHER compensator
STENTS Tissue
recontouring
stents

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
24
 RADIATION CARRIERS - Radiation carriers are used
when radiation is to be administered to a particular area without exposing the unaffected
healthy tissues to radiation. They usually carry capsules, beads, tubes or needles made of
radioactive element such as radium226, iridium192 or cesium132.

PRELOAD AFTERLOAD
• In pre-loaded carriers the radioactive • the radioactive elements are placed
sources ( iridium seeds are after the carrier is in position, which
incorporated within a smaller reduces the radiation exposure to
diameter polyethylene tube within personnel handling and positioning
stent and corrobend sheild) are placed the device. implanted into the tissues
and sealed within the carrier of the tumor

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
25
 POSITIONING –POSITION
MAINTAINING STENT
DENTULOUS
• An interocclusal stent is prepared
that extends lingually from both
occlusal tables with a flat plate of
acrylic resin - to depress the tongue
within the lingual borders of the body
of the mandible.

• A hole is made in the anterior

horizontal segment and the patient is
instructed to maintain the tongue tip
in this orientation hole during
treatment- a consistent reproducible
tongue position

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
26
 EDENTULOUS – Casts, record bases, DIRECT TECHNIQUE – softened base
interocclusal records, ½ to 2/3 rd mouth opening, plate wax within patients mouth to desired
mounted, 2 thickness base plate wax to lingual shape and size, indexed to the existing
surface of mandible to depress the tongue. dentition, flasked and procesed
Occlusal index/ duplicated dentures

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
27
POSITIONING – PERIORAL CONE - Small
superficial lesions in accessible locations in the oral cavity may best be treated with a boost of radiation with
a peroral cone. Encompassed, small sized tumour [T1 , T2]

• A custom docking device can be fabricated to orient

the peroral cone in a repeatable position

• Fabrication - tinfoil is wrapped around the actual

cone to be used in the treatment and an acrylic ring
of 4 to 6mm is formed around it.

• The tinfoil acts as a separator from acrylic resin.

• The acrylic ring is then attached to the maxillary

record base in case of edentulous patients and to
the occlusal indices in case of dentulous patients.

• The cone is attached in such a way that it is

centered over the lesion 28
 POSITIONING – DOSIMETER- Dosimeter
is a device which measures the amount of radiation exposure

• The absorbed dose can be calculated by using the formula

• D=AEave*1.6E-13J/MeV*1E3g/kg.
• Where, D= Absorbed dose A=Radioactivity Eave= Average energy E=
HxW1 where H= Equivalent dose W1=Weighing factor J= Joule MeV=
Million electron Volts
• Lithium fluoride capsules are commonly used as dosimeters for its
accuracy and efficacy
• The lithium fluoride capsule is wrapped in a 0.1 inch tinfoil which is
wrapped with acrylic resin casing and is allowed to cure.
• A hole is placed at one end of the stent and an orthodontic wire is used
to push the capsule out of the acrylic resin casing.
• The resin case is attached to the stent in position as directed by the
radiotherapist

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
29
POSITIONING – INTRAORAL positioning
appliance for stereotactic radiotherapy - Stereotactic
radiotherapy is an alternative to conventional surgery and/or conventional radiation therapy

• Intraoral positioning appliance serves as a noninvasive technique

of verification
• The prosthesis consists of tungsten spheres of 3mm diameter
embedded into maxillary occlusal splint.
• edentulous patients - positioner is fabricated over the maxillary
denture and indexed to the mandibular denture teeth.
• If no dentures, then wax occlusal rims on resin record bases- a
centric occlusal position at the correct VDO and tungsten spheres
should be embedded in the palatal portion of the maxillary record
base.
• Orthogonal pair of radiographs will be taken during each
treatment session -verify head position.
• The metal spheres embedded in the intraoral positioning appliance
serve as the reference points to verify the location and orientation
of the head within the stereotactic space
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 SHEILDING STENT -As the name suggests these stents are
intended to shield the vital structures adjacent to the affected tissue from radiation exposure

• Effective shields can be fabricated to

protect the vital structure from
radiation exposure

• Low melting alloys like Cerroband, Pb-

Bi-Sn, and Lipowitz are used as
shielding materials

• . During the fabrication of this stent a

hollow cavity of required thickness in
made in relation to the structure to be
protected.

• Cerrobend alloy is then heated and

poured into the hollow cavity and it is
sealed with auto polymerizing resin.

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
31
 PROTECTING – TONGUE DEPRESSING
STENT
• The purpose of this stent is to depress the tongue
and prevent it from unwanted radiation exposure

• prevents the parotid gland from exposure during

radiotherapy

• A hole is made in the anterior segment in which the

tip of the tongue is placed in order to establish a
reproducible position

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
32
 PROTECTING - DISPLACING
STENT
• They are used to move or displace the
vital structures from the radiation field.

• It is commonly used in the treatment of

tumor involving the alveolus of the
mandible, posterolateral borders of the
tongue and the buccal mucosa.

• The stent is designed in such a way that

it separates the maxilla from mandible,
which prevents maxilla from unwanted
radiation exposure

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
33
 PROTECTING – CUSTOM MOUTH
PROTECTOR
• its application greatly in sports-related activities in
order to prevent injuries.

• Mucositis appears 2 to 3 weeks after the start of

therapy and reaches a peak toward the end of
treatment. -Most severe at tumor site, dysphagia
and weight loss

• The flexible smooth protectors protect painful

edematous mucosal tissues from irritation by tooth
surfaces and irritating foods

• Hypersensitivity of teeth - Daily application of

fluoride gel in custom mouth protectors for 10 to 15
minutes three times a day usually eliminates the
hypersensitivity in 4 to 6 weeks

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
34
 BOLUS COMPENSATOR TISSUE RECONTOURING STENT

• in the treatment of superficial lesions of the • lesions associated with lips.

face with irregular contours
• Due to the curvature of the lip low dose
• areas within the field may be untreated, of radiation is delivered at the corners of
while others may develop isolated hotspots the mouth and high dose at the center.

• Bolus is a tissue equivalent material -
placed directly onto or into the
irregularities, converts irregular tissue
contours into flat surfaces - perpendicular
to the central axis of the ionizing beam, to
thereby more accurately aid in the
homogenous distribution of the radiation.
• This stent serves to flatten the lip and
ensures that its entire length lies in the
same plane.
• These stents are fabricated by modeling
plastic/wax and are processed in acrylic
resin

• The most commonly used materials for

bolus are tissue conditioners, water, saline,
waxes and acrylic resin.

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
35
 TEMPLATE USED IN DIRECT
IMPLANTATION
• Lesions of the tongue and anterior floor of the mouth often are treated by
direct implantation of a radioactive source in the tumor.. The radiation
physicist and

• radiation oncologist determine the position and placement of the implant,

and holes are drilled in the prosthesis to correspond to the desired
placement.

• The prosthesis aids not only in positioning the radiation source, but also in
determining the proper depth of insertion.

• Once the prosthesis is secured and the implants have been placed, a tissue-
conditioning material is flowed over the implants to maintain them in proper
position during the treatment period.

Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996
Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366
36
RADIATION
EFFECTS ON THE
ORAL CAVITY

37
 ORAL MUCOUS MEMBRANE -
MUCOSITIS
• In oral mucosa, radiation effects appear early
in the course of therapy. Initially, an erythema
appears that eventually leads to extensive
ulceration and desquamation, sometimes
resulting in a severe radiation mucositis

• Changes in oral flora - Colonization by gram-

negative bacilli, in particular, appears to
induce more severe mucosal reactions during
the later stages of radiation therapy

38
39
• treatment during therapy has been supportive and
symptomatic (i.e., saline and soda rinses, viscous
xylocaine, systemic analgesics, and so forth). ½
teaspoon of each in glass of warm water – 3-4 hrs

• Occasionally, nystatin oral suppositories, used as a

lozenge, were employed to treat an oral fungal
infection
• Good oral hygiene
• Soft tooth brush, mild tasting tooth paste
• Frequent oral rinses- salt , sodium bicarbonate,
hydrogen peroxide, benydryl elicits, sucrafate solutions,
topical anesthetics

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PD Kumar Madan, PS Sequeira , Kamalaksha Shenoy , Jayaram Shetty. The effect of three mouthwashes on
radiation-induced oral mucositis in patients with head and neck malignancies: A randomized control trial. J Cancer
Res Ther - March 2008 - Volume 4 - Issue 1

• Eighty patients with head and neck malignancies,

scheduled to undergo curative radiotherapy, were
randomly assigned to receive one of the three alcohol-
free test mouthwashes (0.12% chlorhexidine, 1%
povidone-iodine, or salt/soda) or a control.

• The patients were instructed to rinse with 10 ml of

the mouthwash, twice a day, for a period of 6 weeks.

• Mucositis was assessed at baseline and at weekly

intervals during radiation therapy, using the World
Health Organization criteria for grading of mucositis

This study demonstrates that the use of alcohol-free povidone-iodine mouthwash can reduce
the severity and delay the onset of oral mucositis due to antineoplastic radiotherapy, thus
improving the quality of life for patients 41
 TASTE AND OLFACTION
• Taste acuity is readily affected by cancericidal doses of radiation

• CAUSES

- Histologically, taste buds show signs of degeneration and atrophy at 1,000 cGy43

- -the architecture of the buds is almost completely obliterated.

- severe xerostomia may never have normal taste acuity. decrease the number of taste buds and may
alter the form and function of the remaining buds

• since the olfactory epithelium is high in the nasal passage and hence is not included within the
radiation field in treatment of most tumors, the sense of smell is less affected.

12 patients were studied after irradiation of the olfactoiy mucosa. In all 12, smell thresholds for 2 test odorants
increased dramatically after completion of treatment. Six months after radiation treatment, none of the 12 patients had
achieved complete recovery

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EDEMA AND TRISMUS
Edema of the tongue, buccal mucosa, and submental or submandibular
areas is occasionally clinically significant - most prominent - submental
area ; During early postradiation period when scarring and fibrosis
begin to appear

A stent can easily be fashioned to displace the tongue and/or buccal

mucosa and help alleviate this problem. This stent overlays the teeth
and can be fashioned of mouthguard material* on a dental stone cast

Trismus is a disconcerting and often significant manifestation of

cancerocidal doses of radiation therapy. Maximum mandibular
opening may be reduced to 10 to 15 mm.

Dynamic bite opener, exercise, tongue blades held together

with adhesive tapes
43
During radiation therapy, loss of taste acuity, reduced salivary output, and
pain upon swallowing predispose the patient to loss of appetite, nausea, and
malaise

Enriched dietary supplements are useful during this period.

Citrus juices and other acidic foods can result in oral discomfort and should
be replaced with blander items

As oral reactions become more profound, coarse foods should be eliminated

and the diet changed to a soft or semisoft consistency.

DIET
avoid foods which favor an increase in the activity of cariogenic microflora

Dieticians recommendations

44
SALIVARY GLANDS
• Increased viscosity and reduced flow of saliva also
contribute to impairment of taste acuity and poor tolerance
of prosthetic restorations. Swallowing becomes difficult and
appetite is affected

Note fibrosis and lack of

acini in irradiated gland.
these attempts are followed
by the continued
degeneration
of the fine vasculature and
Generally, the younger the patient or the lesser the
progressive fibrosis
dose (below 5000 cGy), the better the chance for
regeneration and recovery.
45
 Their compromise - changes in
oral flora, incidence of caries,
severity of oral mucositis, bone
and soft tissue necroses
 compromise of the buffering
capacity of saliva
 Bicarbonate - decrease as flow
rates decline and the radiation
dose increases
 Compromised peripheral seal
PILOCARPINE - dispensed in liquid
form and used as a mouth rinse (lmg/cc,
5cc per dose, 4 times per day) or in
tablet form (5mg, 3 times per day).
formulate salivary substitutes. Mouth
rinses based on carboxymethylcellulose,
glycerin, and mucin
More fluids
during meal
time, soft diet
Good
oral
hygiene

and retention Use of

prosthetic stents
and splint 46
 BONE - bone is 1.8 times as dense as soft tissue, it absorbs a larger proportion of
radiation than does a comparable volume of soft tissue

• The mandible absorbs more radiation than the maxilla

It becomes virtually a nonvital

tissue.

The marrow exhibits marked

acellularity and avascularity,
with significant fibrosis and
fatty degeneration

well-balanced process of
a: Shown are dentin, cementum, periodontal ligament, destruction and reconstruction
trabeculae, and marrow spaces, b: Take particular
note of avascular and acellular nature of the marrow
is disturbed by
and lack of organized endosteum. c: Haversian systems.
Central artery is often missing. Note empty lacunae

47
PERIODONTIUM
• Its rather specific network of fibers becomes
disoriented and the periodontal ligament
thickens.
• Decreased cellularity and vascularity
• Cementum demonstrates changes similar to
those seen in bone. Capacity to repair and
regenerate lost a: Irradiated periodontal ligament that
received 7000 cGy. Note changes in
• periodontal procedures, such as flap surgery, arrangement of periodontal ligament
in the radiation field should be considered fibers in irradiated specimen,
with caution b: Irradiated periodontal ligament that
received 5000 cGy. Note cellularity,
organization of fibril groups and
improved vascularity compared to

48
subject that received 7000 cGy.
 TEETH
• There appear to be significant changes in pulp
tissue
• Abnormal tooth deposits, excessive osteodentin
by odontoblasts
• the pulp shows a decrease in vascular elements,
fibrosis and atrophy If exposure occurs before significant
• Clinically, pulpal response compromised. calcification is completed, the tooth bud may be
Pulpal pain, however, is less severe, even in the damaged or destroyed.
presence of advanced caries with obvious pulpal
exposure. Exposure at a later stage of development may
arrest growth and may result in irregularities in
enamel and dentin.

The dentitions of those patients receiving

moderate to high levels of radiation- , reflect a
variety of defects that indicate the several
stages of development existing during the
course of radiotherapy 49
 COMPOSITION OF ORAL FLORA
pronounced population shifts in microbial oral flora with cariogenic microorganisms gaining at the
expense of the noncariogenic microorganisms. Longlasting and secondary to xerostomia

Among aerobic organisms, significant increases have been noted in the relative number of Streptococcus
mutans and Lactobacillus at the expense of Streptococcus sanguis, Neiseria, and Fusobacterium.

Brown has reported up to 100-fold increases in fungal populations.

Oral candida – corner of the mouth and beneath the prosthesis

Nystatin- most useful drug - chronic and acute forms of candidiasis, and oral lozenges - most effective
means of delivery.

Considering the high sucrose content of these lozenges (435 mg per lozenge), - accompanied by a strict oral
hygiene regimen and topical fluoride use.

50
DENTAL
MANGEMENT OF
DENTULOUS
PATIENTS

51
 PRE RADIATION EXTRACTION CRITERIA
DENTAL
DISEASE
FACTORS
Dental Disease Factors -
Condition o f the residual dentition
• primary goal - place the dentition in optimal
condition
• high risk dental procedures will not have to be
performed in the posttreatment period.
• All teeth with a questionable prognosis should
be extracted before radiation.
• Mandibular teeth in primary beam –high
scrutiny
RADIATION
DELIVERY
FACTORS
Dental compliance o f the patient
• Hygiene - increasingly difficult after
treatment that results in reduced salivary
output.
• Trismus, impaired motor functions, and
surgical morbidities may also compromise
oral hygiene procedures.
• Patients must possess the motivation and
the physical ability to maintain their
dentition properly.
52
Urgency o f treatment - The status and behavior of the tumor may preclude preradiation dental
extractions; control of tumor - most important consideration

Mode o f therapy - When external radiation is the sole means of radiation delivery, close scrutiny
of the dentition is mandatory because salivary glands and bone will be exposed to higher doses
of radiation (6500 to 7200 cGy).

Radiation fields The risk of caries or necrosis is dependent upon the radiation fields. Consequently,
the fields are important to consider when evaluating the dentition prior to therapy

Mandible versus maxilla Almost all osteoradionecrosis occur in the mandible. Osteoradionecrosis in
the maxilla is rare and, therefore, a conservative approach regarding reradiation extraction of teeth in
the maxilla is justified

Dose to bone The higher the dose, the higher the incidence of postradiation sequelae. For tissues
treated to the highest level of tolerance, a more aggressive program of extracting teeth prior to
therapy is indicated.

53
 Current philosophies and literature
review
Wildermuth and Cantril reported 6 out of 14 patients requiring dental extractions prior to therapy developed bone
necrosis
suggested that extractions prior to radiation were not prudent.
Daly and Drane reported that 22 of 74 bone necroses occurred in patients at the site of preradiation dental
extractions
They suggested that only completely unsalvageable teeth should be removed prior to radiation . teeth should
not be considered for elective removal.
Starcke and Shannon reported that bone necrosis did not occur in any of the 62 patients requiring
preradiation extractions. after a healing period of 25 days

Murray came to different conclusions regarding the efficacy of a conservative policy of extraction of teeth.
conservative policy of tooth removal before therapy may reduce the incidence of bone necrosis
secondary to preradiation dental extraction; post therapy spontaneous necrosis

54
Beumer reported the results using a moderately aggressive philosophy of preradiation extraction

The data and clinical experience indicates that most patients who develop bony necroses are those with
teeth present prior to radiation therapy.
The major dental initiators are:

Healing time is variable and will depend upon host response, degree of surgical trauma
inflicted during tooth removal, extraction location, and the pathology and potential
aggressiveness of the tumor.

Hence, clinical impressions and experience may be the most valuable

tool in making judgments as to when radiotherapy can begin.

Tissue breakdown is thought to be secondary to the dosage from the implant combined
with the external beam dosage, exceeding maximum level of tissue tolerance locally.

55
 Extraction of 3rd molars
• Extraction of impacted mandibular third molars prior to radiation is
not advocated for most patients.

• extractions often necessitate removal of considerable bone, thus

creating large defects requiring prolonged periods for healing.

• Patients with partially erupted mandibular third molars represent

a particularly difficult and perplexing problem because of the risk of
pericoronitis

56
Radical alveolectomy - should be performed, edges of the tissue flaps everted, and primary
closure obtained.

Meticulous care should be exercised in the care of the tissue flaps.

Good surgical technique will pay great dividends in reducing the incidence of complications.

Teeth should be removed in segments in the field of radiation. It is far easier to perform an
appropriate alveolectomy and attain adequate closure by extracting teeth in segments.

Antibiotic prophylaxis

7-10 days – adequate healing – depending on dosage , radiation field and aggressiveness of
tumor

57
 POST RADIATION EXTRACTION
• The risk of bone necrosis secondary to dental extractions in the postradiation period has
been debated by many clinicians

Carl et al, 101 mandibular teeth and 86 maxillary teeth were removed in 47 previously irradiated
patients
Healing was uneventful in most patients, but “delayed” in a few.

no more than 2 or 3 teeth be removed at one time to avoid overtaxing the local blood supply.
preradiation dental extractions represented a greater risk of bone necrosis than postradiation
extractions.

Solomon, 48 patients requiring tooth removal after radiation therapy.

Bone necroses did not occur. This report also stressed the importance of atraumatic tooth removal
in postradiation patients.
58
 In contrast, Daly and Drane, Murray and Monish - discouraged tooth removal in the
field after radiation therapy because of the high risk of osteoradionecrosis. Murray
found that 7 of 8 patients undergoing postradiation extractions developed bone
necrosis
Hoffrneister suggested that, since the rate of wound complications was high in
extractions performed in the post-therapy period, tooth extraction should be performed
prior to radiation.
In the intermediate dose In the low dose
In most high dose category (5500 to 6500 cGy) patient (below 5500
patients, Endodontic therapy - the first cGy),
root canal therapy for option considered;
the affected teeth if not applicable extractions are removed
avoids the risk of unavoidable, atraumatically with
extractions and the to use hyperbaric oxygen as an minimal reflection of
expense of hyperbaric adjunct. the periosteum .
oxygen Single tooth rather
than multiple 59
 DENTAL MAINTENANCE
strict oral hygiene procedures, oral hygiene instruction, and a thorough
and aggressive oral prophylaxis is performed.

Disclosing agents

Fluoride application – The gel is confined to the dentition by these custom-

made carriers and is held in position for 5 minutes once a day

Fluoride treatments are continued for the lifetime of the patient, but may
be reduced if there is evidence of improved salivary function and
continued good oral hygiene
60
Treatment of severe post radiation dental disease

The importance of close follow-up can not be overemphasized. If stringent oral hygiene
measures are not maintained, caries can destroy the entire dentition within 6 months.
The risk of an aggressive caries
attack remains indefinitely.
In the early post treatment period, amalgam
and composite restorations are favored.
Dental extraction of mandibular teeth in the field of radiation should be
contemplated only if conservative measures fail to control the infection
First, during cavity preparation, margins frequently terminate in dentin or cementum
and, as a result, the risk of subsequent microleakage and recurrent decay is high.
Second, moisture control is frequently less than optimal
due to difficulty in controlling gingival hemorrhage
61
ENDODONTIC THERAPY AS AN alternative to postradiation
extraction

A relationship was not found when the length of endodontic fills

and post-endodontic restorative treatment was compared to
subsequent tooth loss.

The short endodontic fills resulted in significantly fewer

periapical changes than either the long or normal fills The
overall retention of postradiation endodontically treated roots
was 85% (46 of 54 roots).

Endodontic therapy of periodontally compromised teeth allows

for coronal amputation and greater access to periodontal pockets

62
OSTEORADIONECROSIS
• Osteoradionecrosis is not primarily an infectious process.
• “exposure of bone within the radiation treatment volume of 3 months
or longer in duration

63
 Treatment options
Osteoradionecrosis Associated with External Beam

local irrigation and packings of iodoform gauze, impregnated with tincture of

benzoin, when the dose to bone in the local area is less than 6500 cGy and the
exposure is localized

When the dose to bone is above 6500 cGy, and the exposure extends beyond
the mucogingival junction, or if the bone exposure occurs in association with teeth
, hyperbaric oxygen combined with a surgical sequestrectomy should be
considered

Antibiotics are necessary only to control local acute infectious episodes involving
the adjacent soft tissues. Routine administration is not advised.

64
 Osteoradionecrosis Associated with External Beam and Interstitial
Implants

The risk of bone necrosis, however, is dependent upon the number and distribution of the interstitial
radiation sources. When the sources are in close proximity to the mandible the risk of necrosis
is high.

However, almost all will heal with conservative measures and will not require aggressive surgery or
hyperbaric oxygen

the outcome of treatment of an osteoradionecrosis, adjacent to an interstitial implant, is determined

by the external beam dose.

If the external beam dose to the bone is below 5500 cGy, the prospects for conservative therapy are
excellent, and surgical sequestration in combination with hyperbaric oxygen is rarely needed

65
 Hyperbaric Oxygen

A major advance in the treatment of osteoradionecrosis has been the use of

hyperbaric oxygen

Patients with bone necrosis were exposed to 2 atmospheres of oxygen in a hyperbaric

chamber for 2 hours per session. Each course of therapy extended for 120 hours.

Nine-amino acridine was used to irrigate the local area daily, and the patients were
placed on systemic tetracycline once oral suppuration had been controlled

Neomycin packings were used in purulent oral wounds. Surgical procedures, such as
extraction and surgical sequestrectomy, were performed between the twentieth and
fortieth treatments.
Alpha-tocopherol (100 mg daily) was administered during the treatment

66
 SOFT TISSUE NECROSIS
Soft tissue necrosis is defined as a nonneoplastic mucosal ulceration occurring in the
postradiation field and which does not expose bone.

Most of these necroses occur within 1 year after completion of radiation therapy

Clinical experience indicates that an appreciable number of soft tissue necroses are precipitated
by cheek and tongue biting.

occlusal adjustments in the dentulous patient, or removal of the mandibular denture in the
edentulous patient, will alleviate the difficulty and reduce the chances of recurrent trauma.

Treatment consists of establishing the diagnosis and close follow-up. In severe cases, healing
can be accelerated by means of hyperbaric oxygen.
67
DENTAL
MANAGEMENT OF
EDENTULOUS
PATIENTS

68
 RISK OF BONE NECROSIS
histopathologic changes - oral mucous membranes and bone, and reduction of
output and compromise of the physical properties and biologic effectiveness of
saliva, some radiotherapists have been reluctant to permit their patients to
wear dentures

Beumer and others reveal that the risk of developing osteoradionecrosis is

minimal if the patient was edentulous prior to radiotherapy.

The risk of osteoradionecrosis is always greater in patients requiring

removal of teeth either prior to or after completion of radiation therapy

performing adequate alveolectomies when extracting teeth in the field of radiation prior to
radiation. The well-balanced process of bone remodeling is seriously disturbed by cancericidal doses
of radiation therapy and, if radical alveolectomies are not performed, the resulting alveolar ridge
will be irregular, possibly increasing the risk of bony exposure in a patient wearing complete
dentures 69
 Soft liners
Silicone liners have been suggested as a means of
minimizing mucosal trauma in mandibular dentures
Clinical experience, however, has confirmed
silicone to be less beneficial than
polymethylmethacrylate.
The silicones exhibit reduced wettability, and this phenomenon contributes to an increased drag
that does not allow the denture to slide as easily over the dry mucosal surface during function.

In patients with radiation induced xerostomia, this

phenomenon assumes added clinical significance.

The high risk of tissue abrasion plus the poor adjustability of silicone
have influenced clinicians to abandon its use in irradiated patients.

In addition, because of the significant increase in fungi populations in patients with

radiation induced xerostomia, more rapid deterioration of silicone liners is observed.

70
 PLACEMENT OF DENTURES
Krajicek suggested that patients could wear dentures after therapy, if 12 to 14 months had elapsed
for mucosal healing. He maintained that, if the mucosa appeared atrophic or ischemic, dentures
would not be tolerated. He also suggested that removable partial dentures should generally not be
considered for postradiation patients, but he provided no data to support this view

Rahn felt that at least 12 to 18 months should elapse after

radiation therapy before considering dentures for a patient. They
suggested that some patients must wait 2 to 3 years before the
mucosa has recovered sufficiently for dentures to be tolerated

Daly and Drane proposed that the clinician

should wait at least 1 year before considering
fabrication of removable prosthetic
restorations for the irradiated patient.

71
 A study by Beumer provides some insight into this clinical dilemma

• In 92 patients who were edentulous prior to the onset of disease (87 having reported previous
experience with complete dentures), 15.4 months following completion of radiation therapy
• None in the group of 92 developed osteoradionecrosis associated with the use of their dentures.

Dentures can be fabricated or reinserted soon after

completion of radiation therapy in most of these patients;
especially when little bone is in the field of exposure
In others, with greater amounts of denture-
bearing area in the fields, a slightly longer
period of recovery is recommended
Experienced complete denture wearers usually have developed the
necessary neuromuscular coordination necessary for successful function
with dentures, and are less likely to exhibit tongue or cheek biting.
An irregular mandibular ridge, in which the entire
body of the mandible is in the field, may prompt the
clinician to defer placement of dentures indefinitely.
Edentulous patients have little risk of developing significant complications from wearing dentures, so,
in most instances, it seems justified to place dentures in these patients 3 to 12 months after radiation
therapy and deferment of dentures for extended periods may be in order for selected patients.
72
DENTURES IN PRE EXISTING BONE NECROSIS
selected patients can use
dentures - , the bone exposures
should be well localized, with
significant amounts of
circumscribing attached mucosa.
The use of dentures over bone exposures in irradiated
patients has been reported to be successful. Employment of
immediate dentures following post radiation extraction is
described by Hart and Mainous. However, all the patients
in their study had received hyperbaric oxygen therapy.
Beumer observed 3 patients with osteoradionecrosis of the edentulous
mandible in the field of radiation and prior to prosthetic treatment. All 3
patients tolerated their restorations successfully without enlargement. Utmost
caution - inserting dentures over bone necroses. Proper relief -in the denture,
and the patient should understand the risks of denture use - close follow-up

73
DENTURES IN PRE EXISTING
SOFT TISSUE NECROSIS
The risk of developing a soft tissue necrosis when wearing complete
dentures, following therapeutic doses of radiation, appears to be
relatively small and die resultant morbidity insignificant

Because of the risk of necrosis,

precautions should be taken to
avoid local trauma and infection.

This is especially important at the

tumor site, for scarring and fibrosis
is most severe at this location.

Extreme care should be taken in

developing the peripheral extensions
of the denture base in these areas.
74
In 1972, Daly and Drane reported
5 cases of osteoradionecrosis in a group of 82 patients receiving intraoral prostheses after
therapeutic radiotherapy to the head and neck region.
Sixty four patients received complete dentures, and 18 received removable partial dentures.
Four healed under conservative treatment

Beumer reported 8 osteoradionecroses attributed to complete dentures or removable partial

dentures.
All but 1 occurred at either a preradiation or postradiation extraction site.
Seven healed with conservative measures accompanied by sequestration of small amounts of
nonvital bone.
The eighth progressively expanded and eventually required a partial mandibular resection.
None of the patients received hyperbaric oxygen.

75
PROSTHODONTIC
PROCEDURES

76
 COMPLETE DENTURES/ REMOVABLE PROSTHESIS
EXAMINATION - Prior to the construction of dentures, the clinician must contact the radiation
therapist ; collect all the information regarding the treatment procedures, inform about the
treatment plant, patient’s attitude and psychosocial state.

appearance of oral mucous membranes -

scarring and fibrosis at the tumor site –
degree of trismus

Status of salivary

The clinician should also examine the denture foundation area thoroughly for undercuts, tori, high
tissue attachments, enlarged maxillary tuberosities, flabby and redundant tissue, lack of attached
gingiva, and abnormal jaw relationships - any condition that compromises prosthetic prognosis in
non-irradiated patients assumes added significance in irradiated patients

77
IMPRESSION –
1. careful border molding ; no over extensions especially in mandibular
lingual region – perforation of mucosa; modelling compound can be used;
2. xerostomia- to avoid sticking of material to dry mucosa- petroleum jelly;
3. stability and support rather than retention – lingual ;
4. edema of tongue and floor of the mouth-limit the tongue space and
posture of the floor-lingula flange limited;
5. any impression material of choice- most familiar with; ZOE may cause
irritation; impression with minimal tissue displacement;
6. mylohyoid area critical spot;
7.removal of residual viscous secretions- guaze- better surface details.

78
VERTICAL DIMENSIONS –
• with record bases using conventional techniques-phonetics, closest speaking
distance, swallowing, neuromuscular perception, and recording vertical
dimension of rest.
• Consider reducing VDO - limit the extent of the forces applied to the
supporting mucosa and bone during a forceful closure.
• clinically significant trismus, entrance of the bolus is more easily
accomplished by increasing the interocclusal space.
• CR - obtained in the usual manner. Wax, plaster, zinc oxide paste, and
silicone are suitable media for obtaining the final registrations.
• Gothic recording devices- no effect on lateral and interborder movements of
mandible.

79
OCCLUSAL FORM
–no particular scheme; However, the authors have come to favor lingualized or monoplane
occlusal schemes with balance facilitated by posteriorly situated balancing ramps.
- The literature seems to indicate that less horizontal force is generated with a nonanatomic
occlusal, would mean an obvious advantage to irradiated patients.
-ln arranging posterior teeth, careful attention should be directed toward attaining a proper
buccal horizontal overlap. Some clinicians use only 3 posterior teeth, 1 bicuspid, and 2
molars in order to avoid trauma to the posterior buccal mucosa.
-In some patients, edema of the tongue and buccal mucosa is prominent, and tongue and
cheek biting is not uncommon. Occlusal trauma may lead to a soft tissue necrosis,
-In dentures constructed with anatomic posterior teeth, bilateral balance is mandatory

80
DELIVERY AND POST INSERTION CARE –
• Occlusal discrepancies caused by processing errors should he eliminated prior to removing
the dentures from the cast.
• rough projections on the tissue surface should be smoothed. Pressure indicator paste - areas
of excessive pressure, and disclosing wax - in delineating overextension of denture flanges.
• Remounting the dentures on a suitable articulator with new maxillomandibular records
made at the time of delivery is mandatory.
• Lightly polishing the bearing surface of the mandibular denture is advisable.
• The patient is given an instruction sheet, detailing possible problems and precautions.
Instructions concerning removal of the dentures if soreness develops, the necessity for
periodic return visits, and the initial limited use of the prosthesis for mastication are
provided. Never worn in sleep.
• During the first week, 24-hour and 48-hour recall appointments are recommended
regardless of how well the patient year. If the patient continues to present without
complications, the interval between visits may be lengthened during succeeding years. Close
recall

81
FIXED PROSTHESIS
Although no substantiating evidence is available, some
clinicians suggest that, if multiple crowns are being prepared,
the patient should be given prophylactic antibiotics.

Exposure of margins should be carefully effected with

retraction cord. Although no sound evidence is available at
this time, it is believed that, the use of electrosurgery for
gingival retraction should be avoided.

Temporary restorations should be well contoured to minimize

gingival irritation.

Pulpal procedures aimed at eliciting secondary dentin

formation are generally not successful.

The compromised vascularity of the pulp and the impaired

capabilities of odontoblasts predispose to failure with direct
or indirect pulp capping techniques.
82
As a general rule, in the patient with severe radiation- induced xerostomia, if crown restorations are
necessary, complete coverage is indicated and, in contrast with patients with normal salivary flow, the
margins are placed subgingivally.

Evidence of radiation caries precludes placement of three-fourths crowns or pin ledge restorations because of
the risk of caries due to the more extensive marginal area.

If there are extensive cervical caries, consideration should be given to performing prophylactic endodontic
procedures followed by amputation of the tooth at the gingiva.

Full coverage restorations may be considered for patients with good oral hygiene and caries control, for key
teeth that serve as partial denture abutments.

Prosthodontically, there are many advantages to restoring abutment teeth with full coverage restorations.

Such teeth can be contoured for optimal placement of retainers, guiding planes and occlusal rests.
However, the judgment to provide extensive restorative procedures must be tempered by the prognosis for
tumor control, general health, oral hygiene, the extent of radiation caries, and the patient’s motivation
83
1. Erickson K T. Et Al. A Technique To Quantify And Reduce Backscatter Due To Metallic Dental Restoration In
Head And Neck Radiation Therapy. International Journal Of Radiation Oncology Biology Physics. September 1,
2014volume 90, Issue 1, Supplement, Page S886
2. Tso T V Et Al. Radiation dose enhancement associated with contemporary
dental materials J Prosthet Dent 2018

• Studies have shown the occurrence of backscatter with the presence of

metallic crowns, metallic restorations, zirconiz crowns and lithium
disilicate crowns
• which can be significantly mitigated with the simple application of at least
5mm of wax or A dental guard / radiation stect and recommend that
dental restorations be recognized during the treatment planning process.
• The use of a radiation stent / wax ; shows less backscatter however,
warrants further study as a method to reduce severe radiation mucositis.

84
IMPLANTS IN IRRADIATED TISSUE

• Long term function of osseointegrated implants is dependent on the presence of viable

bone that is capable of remodeling and turnover as the implant is subjected to stresses
associated with supporting, retaining, and stabilizing prosthetic restoration

• careful consideration such as the risk of osteoradionecrosis, the potential benefit

provided by implants, the potential morbidity associated with implant failure or
complications (such as osteoradionecrosis), and the potential usefulness of hyperbaric
oxygen

Implants in irradiated tissues appear to have significantly lower success rates than

85
 Weinlander and others tested 3 different types of implants using a dog model.
Three implants, Branemark**, IMZ*, and HA coated, were placed on one side of the mandible
in 7 dogs. After 3 months of healing, 21 implants in the 7 dogs were recovered with block
section and served as controls.
After a suitable period of healing, these 3 selected implants were positioned into the
contralateral mandible of each of the 7 dogs.
Radiation commenced 3 weeks later. A dose equivalent to 5000 cGy .
histomorphometric analysis of the bone implant interface.
For the Branemark implant, the appositional bone index was 34% for the non-irradiated
control specimens versus 24% for the irradiated specimens; for the IMZ implants, 50% non-
irradiated controls versus 45% irradiated specimens; and, for the HA coated implant, 69% non-
irradiated controls versus 72% irradiated specimens.

Nishimura has shown that the quality of bone in the implant appositional zone is
compromised, particularly at high radiation dose levels

86
UCLA DATA - By the end of 3 years, however, only 68.4% of the implants in irradiated sites remained in
place as compared to 84.0% of the implants in non-irradiated sites

• The success rates are lower than in normal individuals, even in the maxilla, with its excellent blood supply.
• In addition, the bone-implant interface may be significantly compromised, making the implant less able to
tolerate functional loads. Hyperbaric oxygen appears to help revitalize the bone, leading to improved
success rates, but long-term clinical follow-up data is still lacking.
• In addition, its high cost precludes its use in most patients

87
88
• ALREADY EXISTING IMPLANTS- results in backscatter and, therefore, the tissues on the
radiation source side of the implants receive a higher dose than the other tissues in the field.

• The dose is increased about 15% at 1 mm from the implant

• Dosages ranged from 5000 to 6600 cGy. Based on the findings, Granstom recommended that all
abutments and superstructures be removed prior to radiation and that skin and/or mucosa should be
closed over the implant fixtures. When healing is complete, radiation therapy can begin. Following
completion of radiation, abutments and the superstructure are reattached and the prosthesis remade
or readapted.

89
White et al . Department of Veterans Affairs Consensus: Preradiation dental treatment guidelines for patients with head and neck
cancerHead & Neck. 2019;1–8.

90
Suresh Nayar1,2 . Current concepts and novel techniques in the prosthodontic management of head and neckcancer patients. BRITISH DENTAL JOURNAL |
VOLUME 226 NO. 10 | May 24 2019
91
CONCLUSION
• Radiation therapy has been a boon to the medical profession in the
treatment of patients with malignant conditions.

• Prosthodontists can become a great helping hand to the oncologists and

radiation therapists in improving the quality of the treatment with these
prostheses, there by preventing lot of post irradiation morbidity.

92
 REFERENCES
• Maxillofacial rehabilitation – a prosthetic and surgical approach – John Beumer, Thomas A Curtis, Mark T Maraunick. , 2nd edition. 1996

• Ashish.R.Jain et al Clinical Demonstration of Various Radiation Stents- An Overview /J. Pharm. Sci. & Res. Vol. 8(12), 2016, 1358-1366

• Clinical Maxillofacial Prosthetics – Thomas D. Taylor

• Maxillofacial Prosthetics - WR Laney.

• Maxillofacial Prosthetics : Multidisciplinary Practice – Chalian, Drane & Standish.

• Radiation therapy for oral cavity cancer. DCNA 1990;34(2):205-222.

• Oral tissue changes of radiation oncology and their management. DCNA 1990;34(2):223-238.

• White et al . Department of Veterans Affairs Consensus: Preradiation dental treatment guidelines for patients with head and neck
cancerHead & Neck. 2019;1–8.

• Suresh Nayar1,2 . Current concepts and novel techniques in the prosthodontic management of head and neckcancer patients. BRITISH
DENTAL JOURNAL | VOLUME 226 NO. 10 | May 24 2019

• Erickson K T. Et Al. A Technique To Quantify And Reduce Backscatter Due To Metallic Dental Restoration In Head And Neck Radiation
Therapy. International Journal Of Radiation Oncology Biology Physics. September 1, 2014volume 90, Issue 1, Supplement, Page S886

• Tso T V Et Al. Radiation dose enhancement associated with contemporary

dental materials J Prosthet Dent 2018

• PD Kumar Madan, PS Sequeira , Kamalaksha Shenoy , Jayaram Shetty. The effect of three mouthwashes on radiation-induced oral
mucositis in patients with head and neck malignancies: A randomized control trial. J Cancer Res Ther - March 2008 - Volume 4 - Issue 1
93