Notes From a Course by Dr. Susan Calderer Bank
Here's an outline of useful information regarding dental patients having radiation therapy, transcribed by Dr. David Dutkowski during a course given by Dr. Susan Calderer Bank.
After extraction you need to allow 7-14 days for healing of socket before beginning chemo/XRT (radiation therapy).
Now, using higher voltage, there are fewer side effects than before.
- mucositis (can be severe)
- salivary changes
- infections are not as prevalent as with chemo
Lifetime Side Effects
- decreased pH of saliva
- imbalance of microflora
- perio breakdown
- limitation of opening of mouth
- soft tissue and bone changes
Skin burns are less with the higher power beam.
Dysfunction of Salivary Glands
If major glands are in the field, you can lose 89% of saliva. You need to speak with the oncologist ahead of time to determine whether the salivary glands will be in the field. The saliva becomes very thick and acidic.
You need to monitor the pH of the saliva after treatment and continue to give fluoride as long as it stays acidic. Keep these patients well hydrated. They may need to blenderize their food.
Candidiasis often becomes rampant in the gingival sulcus. The most gentle way to remove candidal substrate is with the end of a tongue depressor. Gauze is too abrasive and the air-water syringe may strip epithelium.
Controlling inflammation is one of your goals in a preventative program-- soft reline for irritating dentures, for example. Candida looks more fuzzy than bacterial infection. Viral infections and bacterial have a red border.
With XRT you see a thickening of the pdl and decreased vascularity disorientation of pdl fibers, decreased vascularity and cellularity, and decreased ability to repair tissue. You should have a pre-treatment CMX.
There can be bone sloughing. Best way to extract maxillary teeth involved with sloughing is to place an ortho elastic around the cervical and to allow the elastic to transport to the apex to avoid trauma from surgical, traditional extraction.
Loss of sensation of taste is a common side effect of XRT (and chemo); it takes almost 3 months to recover this sense after treatment. This is difficult in terms of the patient trying to maintain nutrition.
Saliva (lubricating function)
In xerostomia you often see a breakdown of the incisal edges due to friction; often followed by caries. In prevention program, you can add sealants to these exposed edges.
If you need to extract teeth after XRT, you heed to consult with the oncologist for the field involved. You want PRIMARY closure with close suturing whether you normally would need to or not. Cover with antibiotics.
Have your patient open their mouth 25 times, 3x/day, as wide open as they can in order to maintain full range of mobility.
Decreasing since the advent of megavoltage radiation, osteoradionecrosis can be massive or focal. Hyperbaric oxygen mostly affects the soft tissue, is rare, expensive for extractions, and is falling out of favor of other preventive protocols. However, it is still recommended where and when available, so long as the other preventative protocols are followed.
Often is related to periodontal disease.
In working on a preventative program, avoid heroics. If a tooth is compromised, get it out before CA therapy.
Denture sore spots can lead to osteoradionecrosis.
Oral Health During CA Treatment: Goals
- modify oral environment
- control negative changes
- maintain oral hygiene
- extract compromised teeth - no heroics
- exam and control of existing oral disease
You need to know the treatment they will be going through so you can plan ahead. These patients in your office are often scared and confused. Pre-treatment work-up cleaning is important.
CMX fluoride trays put relief along the border to establish a reservoir if they have severe nausea, you can alternatively have them clean their teeth and then brush on the fluoride.
Preventive Behavior By Patients
- limit sugar
- apply fluoride
- floss is only effective for convex teeth surfaces
- stimudents are effective (also Superfloss and Prox-a-brushes, but these are more abrasive)
- baking soda is effective to raise the pH of the saliva (can rinse and/or brush)
- Maalox is good for early/small ulcerations ( transport with a q-tip)
Chlorhexidene 1 oz three times a day is very helpful. Fluoride rinses are good but not as effective as gels.
Mucositis was not an issue for this one guy who was rinsing with KAMILLOSAN. This has found to be very strong in preventing mucositis.