Management of Irradiated Patients
by Richard A. Fagin D.D.S.

Recently I treated two patients: one who was a high risk for osteoradionecrosis and needed extractions; and another about to receive high doses of radiation for treatment of pharyngeal cancer.  I thought it might be informative to briefly summarize the information I collected as it relates to these patients.

1) Management Before Radiotherapy:

a.Caries control, prophylaxis, and impressions for fluoride carriers.  Teeth with apical disease or periodontal disease should be removed as should clinically sound teeth in the mandible that will be in the direct path of radiation of 6000rads or more.  
b. Maxillary teeth are more resistant to osteoradionecrosis due to their better blood supply and thinner bone. Sound teeth with excellent periodontal health can be preserved even with the level of 6000rads.
c. Dental implants, if considered, are best placed at this time.
d. Studies have shown that 21 days is the ideal time of healing after extractions before radiation begins. However, the risk decreases after just 14 just days.

2) Management During Radiotherapy:

a. Once radiotherapy is started it is best not to interrupt treatment. The patient's problem should be controlled with non-invasive methods.
b.  Alternatives to tooth extractions include: endodontic treatment, incision and drainage, antibiotics, and analgesics.
c.  Within the first four months after radiation, the so-called "golden window," definitive care, including extraction without Hyperberic Oxygen (HBO), can be accomplished.

3) Management After Radiotherapy:

a.Excellent oral hygiene, maintenance, and fluoride treatment.
b.After the first four months post radiotherapy the ability of the jaw to heal decreases.  After this time the standard protocol for HBO is recommended prior to any extraction of teeth.  That protocol consists of 20 sessions at 2.4 atmospheres for 90 minutes prior to surgery and 10 sessions after surgery. Prophylactic antibiotics are also recommended.

4) Complications and their Management:

a.Radiation Caries - Due mainly to pulpal necrosis and odontoblast death.  The enamel is lost from the dentin due to dehydration and deteriorates at the CEJ which requires close follow-up and restorative care.
b.Xerostomia - Evian atomized water spray or Pilocarpine (Salagen) 5 mg PO tid.
c.Osteoradionecrosis - Avoid injury to soft tissue or bone. Hyperberic Oxygen therapy prior to elective surgery.  The tissue recovers for a few months after the initial radiation, hence the "golden window".  Unfortunately after this short initial recovery it only gets worse with time and the jaw continues to be more susceptible to this complication.
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