Preradiation dental extraction decisions in patients with head and neck cancer

To extract or not extract teeth prior to head and neck radiotherapy? A systematic review and meta-analysis

PURPOSE

Teeth with poor prognosis are generally recommended to be extracted prior to head and neck radiotherapy (RT) to reduce the risk of developing osteoradionecrosis (ORN), although controversies have been reported. The present systematic review aimed to determine whether tooth extraction prior to head and neck RT may be associated with a reduced risk of developing ORN compared to dental extraction during or after RT.

METHODS

The review protocol was registered in PROSPERO (CRD42021241631). The review was reported according to the PRISMA checklist and involved a comprehensive search of PubMed, Scopus, Embase, Cochrane Library, LILACS, and Web of Science, in addition to the gray literature. The selection of studies was performed in two phases by two reviewers independently. The risk of bias of individual studies was analyzed using the Joanna Briggs Institute checklist for cross-sectional studies, and the certainty of evidence was assessed using the GRADE tool.

RESULTS

Twenty-eight observational studies were included in the qualitative synthesis, which showed substantial heterogeneity regarding the association between the timing of tooth extraction and ORN development. Twenty-seven of 28 studies were pooled in a meta-analysis that demonstrated a significant association between an increased risk of ORN and post-RT tooth extraction (odds ratio: 1.98; 95% CI: 1.17-3.35; p = 0.01).

CONCLUSION

It was confirmed with moderate certainty that dental extractions should be performed prior to the start of head and neck RT to reduce the risk of ORN.

Pre-radiotherapy dental extractions in patients with head and neck cancer: a Delphi study

OBJECTIVES

To gain a consensus from consultants in restorative dentistry about the types of teeth that should be extracted from head and neck cancer patients (HNC) pre-radiotherapy.

MATERIALS

Literature- and clinician-informed questionnaires were emailed to an 'expert panel' of consultants (n = 24/28; 86%) in the United Kingdom (UK) and Ireland on three consecutive occasions (Delphi rounds). The results of Round 1 were used to revise the questionnaire that was distributed in Round 2, and this procedure was repeated for Round 3. During Rounds 2 and 3, participants were asked to indicate, on a 5-point Likert scale, their level of agreement with a series of statements on the types of teeth that should be extracted pre-radiotherapy. The target level of consensus for each statement was 70%.

RESULTS

In Round 2, there was consensus-agreement for 69 of 102 statements (i.e. ≥ 70% of participants rated 'agree' or 'strongly agree' to the relevant statement). Consensus agreement was also achieved for 20 of 28 statements in Round 3. Therefore, a total of 89 consensus statements are presented that illuminate the decision-making process for the pre-radiotherapy extraction of molar, premolar, and anterior teeth with periodontal pocketing, furcation disease, mobility, caries, tooth-wear, apical disease, or other pathology.

CONCLUSION

The statements represent the consensus professional views of participated consultants in restorative dentistry in the UK and Ireland regarding the types of teeth that should be extracted from HNC patients pre-radiotherapy. The results provide a platform for the development of future guidelines.

CLINICAL SIGNIFICANCE

Pre-radiotherapy dental assessments for head and neck cancer patients are considered mandatory. This study presents different criteria that should be considered for the treatment planning of these patients in relation to pre-radiotherapy extractions, according to the collective consensus opinion of participated consultants in restorative dentistry in the UK and Ireland.

Clinical registry of dental outcomes in head and neck cancer patients (OraRad): rationale, methods, and recruitment considerations

Background

Most head and neck (H&N) cancer patients receive high-dose external beam radiation therapy (RT), often in combination with surgery and/or chemotherapy. Unfortunately, high-dose RT has significant adverse effects on the oral and maxillofacial tissues, some of which persist for the life of the patient. However, dental management of these patients is based largely on individual and expert opinion, as few studies have followed patients prospectively to determine factors that predict adverse oral sequelae. In addition, many previous studies were conducted before wide-spread adoption of intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy. The objective of this multi-center study is to systematically evaluate the oral health of subjects for 2 years after commencement of RT, with the goal of identifying risk factors that predict adverse oral outcomes post-RT.

Methods

This is a prospective multi-center longitudinal cohort study of H&N cancer patients who receive high-dose RT with curative intent. Planned enrollment is 756 subjects at 6 primary clinical sites (and their affiliated sites) in the USA. A baseline visit is conducted prior to the beginning of RT. Follow-up visits are conducted at 6, 12, 18 and 24 months from the start of RT. The primary outcome measure is the 2-year rate of tooth loss in patients who have received at least one session of external beam RT for H&N cancer. Secondary outcome measures include the incidence of exposed intraoral bone; incidence of post-extraction complications; change in Decayed Missing and Filled Surfaces (DMFS); change in periodontal measures; change in stimulated whole salivary flow rates; change in mouth opening; topical fluoride utilization; chronic oral mucositis incidence; changes in RT-specific quality of life measures; and change in oral pain scores.

Discussion

This study will contribute to a better understanding of the dental complications experienced by these patients. It will also enable identification of risk factors associated with adverse outcomes such as tooth loss and osteoradionecrosis. These findings will support the development of evidence-based guidelines and inform the planning of future interventional studies, with the goal of advancing improvements in patient care and outcomes.

Trial registration

ClinicalTrials.gov Identifier NCT02057510, registered 5 February 2014.

Bacterial diversity in medication-related osteonecrosis of the jaw

OBJECTIVE

The aim was to study the association between microflora and medication-related osteonecrosis of the jaw (MRONJ) by using culture-independent molecular techniques to detect bacteria in necrotic bone lesions.

STUDY DESIGN

Included were 18 consecutive patients with MRONJ, 10 with osteoporosis and 8 cancer patients. Bone biopsies were retrieved from the center of the necrotic bone and from visually healthy bone, and 16 S rRNA gene fragments from bacterial DNA were amplified with polymerase chain reaction.

RESULTS

The study revealed a diversity of bacteria represented by 16 S rRNA sequences in all the necrotic bone samples and in 60% of the visually healthy bone. Eight dominating taxa groups were identified at the genus level: Porphyromonas, Lactobacillus, Tannerella, Prevotella, Actinomyces, Treponema, Streptococcus, and Fusobacterium.

CONCLUSIONS

The necrotic bone lesions contained mainly anaerobic bacteria, representative of periodontal microflora, suggesting that a periodontal infection in combination with antiresorptive treatment could initiate osteonecrosis.

Dental extractions prior to radiotherapy to the jaws for reducing post-radiotherapy dental complications

BACKGROUND

Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage.

OBJECTIVES

To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed. 

SELECTION CRITERIA

Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the results of the searches for inclusion in the review. 

MAIN RESULTS

No randomised controlled trials were found.

AUTHORS' CONCLUSIONS

There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws.

Access to dental services for head and neck cancer patients

Dental assessment is important for patients with cancer of the head and neck who are to have radiotherapy, as many of these patients have poor dental health before they start treatment. This, compounded by the fact that radiotherapy to the head and neck has a detrimental effect on oral health, has led the National Institute for Clinical Excellence (NICE) to issue guidance that the dental health of these patients should be assessed before treatment. Unfortunately some multidisciplinary teams, such as the one at United Lincolnshire Hospitals, do not have access to a restorative dentist or a dental hygienist. In a retrospective survey we investigated access to general dental services by patients with head and neck cancer who were to have radiotherapy at our hospital and found that 37/71 (52%) had not been reviewed by a dentist within the past 12 months. A secondary national survey that investigated the availability of restorative dental and dental hygienic services showed that of the 56 multidisciplinary teams that deal with head and neck cancer in England, 19 (34%) do not have access to a restorative dentist and 23 (41%) do not have access to a dental hygienist, suggesting that this problem may be countrywide.

Repercussões da radioterapia na região orofacial e seu tratamento

A radioterapia em região de cabeça e pescoço provoca inúmeras sequelas ao paciente irradiado, afetando o sistema estomatognático e com repercussões sistêmicas importantes. As sequelas da radiação ionizante podem ser extensas e, algumas vezes, permanentes, em especial nas glândulas salivares e no tecido ósseo. É relevante que o cirurgião dentista tenha conhecimento das reações adversas e das formas adequadas de prevenção e tratamento para amenizar o desconforto e melhorar a condição de vida do paciente irradiado. Portanto, a conscientização e motivação deste paciente, com a promoção de saúde oral através da adequação do meio bucal e orientações sobre ações preventivas, são essenciais para se obter o melhor prognóstico.

Dental needs in brazilian patients subjected to head and neck radiotherapy

In spite of its recognized benefits in the treatment of malignant tumors, radiation therapy have several side effects in the head and neck region. The evaluation of oral conditions by a dentist is important to prevent or minimize these problems. The aim of this retrospective review was to analyze the dental needs in 357 patients who received radiotherapy in the head and neck region and were treated at Orocentro/FOP/UNICAMP, between January 1990 and December 2004. Review of patient files showed that dental examination before radiotherapy was not performed in 148 patients (41.5%) and was done in 209 patients (58.5%). From the total of examined patients, 94 (45%) did not require dental procedures at the moment of examination, while 115 (55%) presented some sort of dental need. Following the patients after the radiotherapy, it was observed that the group of patients that was evaluated before radiation presented less need of restorations, root canal filling and dental extractions than those who were not evaluated. The results of this study confirm that the evaluation of oral conditions prior to radiotherapy is essential to minimize the dental needs, emphasizing the importance of the dentist in the multidisciplinary team that treats cancer patients.

Dental extractions in the irradiated head and neck patient: a retrospective analysis of memorial sloan-kettering cancer center protocols, criteria, and end results

BACKGROUND

This study was designed to use our institutional experience with irradiated head and neck patients to evaluate 1) dental extraction incidence and sequelae; 2) those patients who developed osteoradionecrosis via extraction and the efficacy of hyperbaric oxygen therapy; and 3) guidelines for extraction protocols in this population. Materials and methods A group of 1,194 patients with a history of radiation to the head and neck, who were evaluated and treated in the Dental Service at Memorial Sloan-Kettering Cancer Center, were reviewed. The 187 who required dental extractions were analyzed using patient demographics, tumor location, staging, histopathology, radiation dosage, field, and timing, dental extraction indications, location, surgical methods, and sequelae.

RESULTS

Almost 85% of the patients reviewed did not require extraction. Only 4 of those who underwent extractions at Memorial Sloan-Kettering Cancer Center developed osteoradionecrosis.

CONCLUSIONS

The use of multidisciplinary team communications and careful extraction selection by prognosis and symptomatology regardless of preexisting dental pathologies, atraumatic extraction procedures, and meticulous follow-up can lower both extraction and osteoradionecrosis rates.

Modified Delphi survey for decision analysis for prophylaxis of post-radiation osteonecrosis

OBJECTIVES

to augment epidemiological data from the literature, assist Bayesian perspectives and a decision analytic framework for the minimization of post-radiation osteonecrosis (PRON; osteoradionecrosis) and its impacts in irradiated head and neck cancer patients.

MATERIALS AND METHODS

a modified Delphi process survey of 15 international clinical experts was used to identify and assess outcome data and factors related to PRON risk, extraction, and factor suitability for formal decision analysis. Clinimetric pain and function outcome scales were created and assessed for relevance to quality of life.

RESULTS AND CONCLUSIONS

expert opinion qualitative assessments were generally adequate and consistent between open- and close-ended items, but many quantitative (e.g. PRON risk rate) estimates were not. A research agenda advocated to validate the epidemiological database for minimization of PRON and decision analysis includes: adoption of a uniform definition of PRON, and ICD code for non-experimental databases; more detailed, consistent data reporting in articles; and quality of life studies.