Radiation &Chemotherapeutic

Issues in Dentistry

Pauline Tran
DDS 2020
Hoang Mai
66 year old female

CC: “I want to take out my lower teeth and get full

dentures. I also want to get new upper dentures.”
HCC: she wants to take out her teeth because she feels like
they are rotten
Dental Hx: previously got dental tx in vietnam, currently
wears an upper complete denture
Med Hx: Previous chemotherapy for breast tumor, gerd,
spinal cord injury
Allergies: NKDA
SH: lives in sf with her husband, has 4 kids
Medical History
• Hx of chemotherapy for breast tumor, GERD, spinal cord injury
• Medications:
• Anastrozole – anti cancer hormone therapy taken orally
• Pantoprazole – proton pump inhibitor for tx of GERD
• Baclofen – muscle spasms from spinal cord injury
Intraoral Photos
Pano
Mandibular Perio Chart
Hard Tissue Chart
Findings
Plaque Index: 2.0
ATP count: 2248
PH: 5.5-6.9
Caries Risk: High
due to high ATP count, active caries, visible heavy plaque on teeth

Perio Dx: Stage 4, Grade B based on number of teeth that have been lost
Etiology: Bacterial plaque, calculus, poor oral home care, no regular dental visits
Prognosis: Fair with improved oral hygiene and regular recalls
Hard Tissue Findings

• #21 – previously endo treated w/ symptomatic apical

periodontitis
• #22 – MFL filling missing
• #28 – extensive decay under crown margins
TREATMENT PLAN ALTERNATIVE TREATMENT PLAN
Urgent Phase: N/A Urgent Phase: N/A

Disease control: Disease control:

• OHI, SRP LL & LR, ITE • OHI, SRP LL & LR, ITE
• Fluoride varnish, CHX • Fluoride varnish, CHX
• Endo retreat #21 • Endo retreat #21
• #22 MFL comp • #22 MFL comp
• Ext #28 • Ext #28

Reconstructive: Reconstructive:
• Section distal cantilever pontics from #20 Section distal cantilever pontics from #20
• Section distal cantilever pontics from #29 Section distal cantilever pontics from #29
• Section #20 from #21 (splinted) Bridge to replace #28 w/ abutments on #27, 29
• #20, 21, 29 PFM survey crowns Implant #19, 30
• Lower RPD Remake upper complete denture
• Remake upper complete denture
Maintenance:
Maintenance: 4 month recall
4 month recall
 Treatment Considerations
Metastasis to oral cavity
• Most common sources of tumors that metastasize to the oral cavity are the breast, lung,
kidney
• Mandible is the most commonly involved location for metastasis, specifically the molar region
• Radiographic appearance: solitary radiolucency in jaw or moth-eaten appearance
• Oral soft tissues may be a target as they are rich in capillaries which can entrap malignant
tumor cells and lead to further proliferation

Treatment
• May involve surgical resection, radiation, chemotherapy, or a combination

Kumar, Gs, and Bs Manjunatha. “Metastatic tumors to the jaws and oral cavity.” Journal of oral and maxillofacial pathology : JOMFP vol. 17,1 (2013): 71-5.
doi:10.4103/0973-029X.110737
 Treatment Considerations
If patient was scheduled to undergo radiation therapy for this metastasis…

Questions to ask radiation oncologist:

1. What is the type of cancer and where is it located?
2. What is the proposed dose of radiation and what are the exact areas to
be radiated?
3. How much radiation will the jaws, teeth, and salivary glands receive?
4. What is the expected schedule of the radiation therapy?

Barker BF, Barker Gerry J. Oral Management of the Patient with Cancer in the Head and Neck Region. Journal of the California Dental Association. 2001.
 Post-Radiation Prosthetics
• Gerngross, PJ et al. investigated the number of complications associated w/
removable prostheses in patients following radiation therapy to the head & neck
• Also evaluated whether the time between radiation therapy and denture
insertion contributed to those complications
• Overall, majority of patients did not experience any complications
• For the ones that did, they found that patients who got their dentures in 180
days or less had the same number of complications as those who received their
dentures in 181-365 days and those who had to wait for over a year

Gerngross PJ, Martin CD, Ball JD, et al. Period between Completion of Radiation Therapy and Prosthetic Rehabilitation in Edentulous Patients: A Retrospective Study.  Journal of
Prosthodontics. 2005;14(2):110-121. doi:10.1111/j.1532-849x.2005.00014.x
 Post-Radiation Implants
• Zen Filho, EV et al evaluated the safety of dental implants placed in irradiated bone and their viability
when placed post-radiation therapy
• 331 patients, 1237 implants  overall failure rate 9.53%
• Time interval between radiation and implant placement did not impact implant failure rates
• Time delay Ranged from 1 month to 20 years
• Greater time delay has not been proven to show better clinical results
• Some of the studies reviewed found a lower survival rate in patients irradiated with >50 gy while
other studies reported no significant difference
• Successful osseointegration was observed in both the maxilla and mandible
• Results suggest that Implant placement in irradiated bone is viable and should not be ruled out as a
treatment option

Filho EVZ, Tolentino EDS, Santos PSS. Viability of dental implants in head and neck irradiated patients: A systematic review.  Head & Neck. 2015;38(S1).
doi:10.1002/hed.24098
 Oral Health Status & Osteoradionecrosis

• Katsura, Kouji et al assessed oral health status as a risk factor for

osteoradionecrosis
• Significant association of osteoradionecrosis with oral health when the
following conditions were present: pocket depths >5 mm, >40% plaque
scores, and >60% bone loss
• Good oral health status after radiotherapy is essential in preventing
osteoradionecrosis
• Reinforces importance of good home care and regular recall visits

Katsura K, Sasai K, Sato K, Saito M, Hoshina H, Hayashi T. Relationship between oral health status and development of osteoradionecrosis of the mandible: A retrospective
longitudinal study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2008;105(6):731-738. doi:10.1016/j.tripleo.2007.10.011
 References

Barker BF, Barker Gerry J. Oral Management of the Patient with Cancer in the Head and Neck Region. Journal of the California Dental
Association. 2001.

Gerngross PJ, Martin CD, Ball JD, et al. Period between Completion of Radiation Therapy and Prosthetic Rehabilitation in Edentulous
Patients: A Retrospective Study. Journal of Prosthodontics. 2005;14(2):110-121. doi:10.1111/j.1532-849x.2005.00014.x

Filho EVZ, Tolentino EDS, Santos PSS. Viability of dental implants in head and neck irradiated patients: A systematic review. Head &
Neck. 2015;38(S1). doi:10.1002/hed.24098

Katsura K, Sasai K, Sato K, Saito M, Hoshina H, Hayashi T. Relationship between oral health status and development of
osteoradionecrosis of the mandible: A retrospective longitudinal study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontology. 2008;105(6):731-738. doi:10.1016/j.tripleo.2007.10.011

Kumar, Gs, and Bs Manjunatha. “Metastatic tumors to the jaws and oral cavity.” Journal of oral and maxillofacial pathology :
JOMFP vol. 17,1 (2013): 71-5. doi:10.4103/0973-029X.110737