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A representative case of jawbone exposure (case 3). a Positron emission tomographic image before radiation therapy (RT). b Simulation computed tomographic (CT) image. Jawbone exposure developed around the left mandibular wisdom teeth. c Note the bone destruction on the lingual side of the wisdom tooth in CT image. The wisdom tooth was not prophylactically extracted because the tooth was asymptomatic and deeply impacted. d Panoramic X-ray image before RT showing the deeply impacted left mandibular wisdom tooth. e Intraoral finding after 11 months RT showing severe trismus and the deep periodontal pocket into which the tips of tweezers were deeply inserted. f Intraoperative finding. Note the minimal mucosal defect on the lingual side of the deeply impacted wisdom tooth. g Intraoral finding 5 months postoperatively showing sufficient mouth opening and epithelialization
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Background
The purpose of this study was to investigate the effectiveness of dental intervention before and after radiation therapy (RT) for head and neck malignancy on prevention of osteoradionecrosis (ORN) of the jaws.
Methods
This is a single-arm prospective study according to intervention protocol of prophylactic dental extraction before RT an...
Citations
... Because oral hygiene is a risk factor for ORN development [36,37], this study demonstrated that satisfactory oral and ORN lesion area hygiene proved to be a protective factor for clinical success. A study did not nd conclusive evidence regarding the removal of oral infection foci before RT [38]; ...
... however, oral hygiene guidance from the time of preradiotherapy conditioning to post-RT follow-up is of utmost importance in raising awareness and managing oral health throughout the treatment and the patient's life as a healthy habit [25,34,36,37,39,40]. ...
Objective: To compare the treatment of ORN using a protocol containing antimicrobial photodynamic therapy with a conventional protocol.
Methodology: A retrospective study of 55 patients who had presented with ORN at a reference hospital between 2002 and 2021 and received treatment by two clinical protocols was conducted. Clinical treatment success was defined as the epithelialization of the ORN lesion and absence of painful symptoms and local infection.
Results: The study included 53 ORN lesions with a median ORN development time of 30 months; 83.02% were men, with a median age of 58 years. The main etiologies of ORN included prosthetic trauma (28.30%) and dental extractions caused by infection (32.07%). Satisfactory oral hygiene and lesion hygiene, when compared with the outcome of lesion epithelialization, were found to be protective factors for achieving clinical success (p ≤ 0.0001). ORN developed more rapidly in oral cavity tumors (median of 8 months) than in oropharyngeal tumors (39 months) (p = 0.01).
Conclusion: Compared with the conventional protocol, the proposed protocol demonstrated effectiveness, achieving clinical success in a shorter time in 75% of the analyzed lesions (p ≤ 0.0001). Maintaining oral and lesion hygiene is a protective factor for achieving clinical success. ORN develops more rapidly in oral cavity tumors.
... The first step in the prevention of osteoradionecrosis is a clinical examination of the patient before radiation. It is necessary to identify the teeth that need to be extracted, to inform patients about complications during radiotherapy and how to mitigate them, and to inform patients about the importance of preserving the health of the oral cavity and teeth after radiation [55,56]. ...
Osteonecrosis of the jaw is a condition in which bone cells die due to various causes. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis. Antiresorptive or antiangiogenic drugs cause drug-induced osteonecrosis. The combination of medications, microbial contamination, and local trauma induces this condition. Osteoradionecrosis is a severe radiation therapy side effect that can affect people with head and neck cancer. It is described as an exposed bone area that does not heal for longer than three months after the end of radiation treatment with the absence of any indications of an original tumor, recurrence, or metastasis. Trauma (tooth extraction), tumor site, radiation dose that the patient receives, the area of the bone which is irradiated, oral hygiene, and other factors are risk factors for the development of osteonecrosis. Less frequently, osteonecrosis can also be induced by non-traumatic and traumatic causes. Non-traumatic osteonecrosis is brought on by infections, acquired and congenital disorders, as well as the impact of chemicals. Traumatic osteonecrosis is brought on by thermal, mechanical, or chemical damage. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient’s quality of life, and surgical, which involves debridement of the necrotic bone.
... After confirming the eligibility criteria and discussing the divergences, 72 studies were selected for full-text reading. Finally, following eligibility criteria confirmation, 28 studies were selected for qualitative and quantitative analysis [8,9,[11][12][13][14][15][16][17][18][19][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41]. Cohen's kappa statistic for inter-reviewer agreement in phase 2 was 0.801 (p = 0.000). ...
... [18] performed descriptive frequency analysis and found that a higher prevalence of ORN was associated with pre-RT extractions, which indicates that pre-RT extractions may present a greater risk than post-RT extractions, although the assumption was based on small samples and low prevalence numbers. In agreement, other studies did not find a difference in ORN development between tooth extraction before and after RT, thereby demonstrating that the risk of ORN is present regardless of when the extractions are performed, which precludes the possibility of determining that the best time to extract teeth is prior to the start of RT [15,17,19,35,36,38] Retrospective studies assessing general potential risk factors for the occurrence and severity of ORN were also included in this systematic review since tooth extractions were among the risk factors. Caparrotti et al. [14] found that pre-RT dental extractions had a statistically significant association with ORN (p = 0.045). ...
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.
... The authors stated on request that one patient had a dental extraction prior to IMRT which did not heal well, leading to ORN 2 months after IMRT. In four patients, dental extractions The preradiation dental extraction percentages do not add up to 100% because extraction data were not available/known for some patients b Reported combined more cases as the total population c The preradiation dental extraction percentages do not add up to 100% because edentulous patients were not counted as "Patients without extractions prior to IMRT" and dental status was not available for 1 patient d Calculated (total IMRT patients-patients with extractions after IMRT) Strahlenther Onkol [30]. Four patients received post-IMRT extractions. ...
Objective
To seek evidence for osteoradionecrosis (ORN) after dental extractions before or after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC).
Methods
Medline/PubMed, Embase, and Cochrane Library were searched from 2000 until 2020. Articles on HNC patients treated with IMRT and dental extractions were analyzed by two independent reviewers. The risk ratios (RR) and odds ratios (OR) for ORN related to extractions were calculated using Fisher’s exact test. A one-sample proportion test was used to assess the proportion of pre- versus post-IMRT extractions. Forest plots were used for the pooled RR and OR using a random-effects model.
Results
Seven of 630 publications with 875 patients were eligible. A total of 437 (49.9%) patients were treated with extractions before and 92 (10.5%) after IMRT. 28 (3.2%) suffered from ORN after IMRT. ORN was associated with extractions in 15 (53.6%) patients, eight related to extractions prior to and seven cases related to extractions after IMRT. The risk and odds for ORN favored pre-IMRT extractions (RR = 0.18, 95% CI: 0.04–0.74, p = 0.031, I² = 0%, OR = 0.16, 95% CI: 0.03–0.99, p = 0.049, I² = 0%). However, the prediction interval of the expected range of 95% of true effects included 1 for RR and OR.
Conclusion
Tooth extraction before IMRT is more common than after IMRT, but dental extractions before compared to extractions after IMRT have not been proven to reduce the incidence of ORN. Extractions of teeth before IMRT have to be balanced with any potential delay in initiating cancer therapy.
... Therefore, patients are referred to a dentist for a pre-treatment assessment, including treatment of dental pathologies, within eleven days of the multidisciplinary conference. This assessment is performed in order to reduce the risk of the severe side effect of osteoradionecrosis of the jaws (ORNJ), due to hypovascularity and reduced healing (Kunskapsbanken, 2018;Muraki et al., 2019;Willaert et al., 2019). Radical dental treatment, such as prophylactic tooth extractions (PTE) (Lockhart & Clark, 1994;Turner, Mupparapu, & Akintoye, 2013), may impair both the patient's appearance and oral functions, such as chewing and swallowing (Clough, Burke, Daly, & Scambler, 2018;Parahoo, Semple, Killough, & McCaughan, 2019). ...
Objectives
The impact of dental occlusion on the experiences of head and neck cancer patients and their oral, social and psychological functioning has been sparsely investigated. There is a lack of knowledge regarding the experience of tooth loss and dentures among patients treated for head and neck cancer. The aim of this study was to describe the experiences of head and neck cancer patients of prophylactic tooth extractions and temporary removable dentures, 6 months after radiotherapy treatment.
Material and methods
An individual interview with 25 patients 6 months after radiotherapy was subjected to a qualitative content analysis.
Results
Two categories, Impaired oral function and Belief in the future, and seven subcategories described the patients' experiences of temporary removable dentures during the first 6 months after prophylactic tooth extractions. The temporary removable dentures affected the patients' ability to chew, swallow and speak, caused pain, and were experienced as an enemy. Despite that, the patients were hopeful and had a wish for recovery, which gave them the energy to live.
Conclusion
Prophylactic tooth extractions and temporary removable dentures 6 months after radiotherapy treatment affect head and neck cancer patients' recovery and everyday life. However, they have the will to take on these challenges, pertaining not only to themselves, but also to relatives and health professionals. At the individual level, the patient needs individualized professional support to get through the arduous procedure, from the acute situation until the end of the rehabilitation phase.
... A systematic review by Nabil and Samman (2011) showed that dental extraction within 1 year after RT resulted in a 7.5% risk of ORN. The risk of ORN caused by dental extraction increased to 22.6% from 2 to 5 years after RT and then decreased to 16.7% after 5 years (Muraki et al., 2019;Nabil & Samman, 2011). Chen et al. (2016) found that their institute avoided dental extraction within 2 years after RT because the average duration between RT and dental extraction was 27.3 months. ...
Objective:
Radiotherapy (RT) carries a substantial risk for the development of osteoradionecrosis (ORN) of the jaw. This study was performed to investigate the relationship between dental extractions after RT and the development of ORN.
Material and methods:
Thirty-two patients with head and neck cancer who underwent tooth extraction after RT were investigated for correlations between the development of ORN and various factors.
Results:
Post-extraction ORN was diagnosed in 12 (12.1%) teeth of 9 patients. The RT dose against the site of tooth extraction was 62.0 and 37.4 Gy in the ORN and Non-ORN groups, respectively (P < 0.001). The duration from RT to tooth extraction was 41.2 and 28.2 months in the ORN and Non-ORN groups, respectively (P = 0.025). Tooth extraction was significantly associated with ORN in patients with a high RT dose against the site (odds ratio = 1.231) and a longer duration of time from RT (odds ratio = 1.084).
Conclusions:
Extraction of non-restorable teeth and those with a poor prognosis should not necessarily be postponed even when patients are undergoing RT. However, clinicians should pay special attention to postoperative management after tooth extraction in patients with a high RT dose and longer time from RT.
... A time period of 10-14 days is recommended between pre-RT extraction and irradiation [32]. Muraki et al. reported that dental interventions, including dental evaluation, prophylactic dental extraction, and good dental hygiene maintenance, both before and after RT have strong effects in the prevention of ORNJ development [33]. Efforts should be driven toward the prevention of post-RT dental extraction both before and after RT. ...
Abstract Background To evaluate factors associated with osteoradionecrosis of the jaw (ORNJ) in patients with head and neck squamous cell carcinoma (HNSCC), focusing on jaw-related dose–volume histogram (DVH) parameters. Methods We retrospectively reviewed the medical records of 616 patients with HNSCC treated with curative-intent or postoperative radiation therapy (RT) during 2008–2018. Patient-related (age, sex, history of smoking or alcohol use, diabetes mellitus, performance status, pre-RT dental evaluation, pre- or post-RT tooth extraction), tumor-related (primary tumor site, T-stage, nodal status), and treatment-related (pre-RT surgery, pre-RT mandible surgery, induction or concurrent chemotherapy, RT technique) variables and DVH parameters (relative volumes of the jaw exposed to doses of 10 Gy–70 Gy [V10–70]) were investigated and compared between patients with and without ORNJ. The Mann–Whitney U test was used to compare RT dose parameters. Univariate and multivariate Cox regression analyses were used to assess factors associated with ORNJ development. Kaplan–Meier analyses were performed for cumulative ORNJ incidence estimation. Results Forty-six patients (7.5%) developed ORNJ. The median follow-up duration was 40 (range 3–145) months. The median time to ORNJ development was 27 (range 2–127) months. DVH analysis revealed that V30–V70 values were significantly higher in patients with than in those without ORNJ. In univariate analyses, primary tumor site, pre-RT mandible surgery, post-RT tooth extraction, and V60 > 14% were identified as important factors. In multivariate analyses, V60 > 14% (p = 0.0065) and primary tumor site (p = 0.0059) remained significant. The 3-year cumulative ORNJ incidence rates were 2.5% and 8.6% in patients with V60 ≤ 14% and > 14%, respectively (p
... A time period of 10-14 days is recommended between pre-RT extraction and irradiation [32]. Muraki et al. reported that dental interventions, including dental evaluation, prophylactic dental extraction, and good dental hygiene maintenance, both before and after RT have strong effects in the prevention of ORNJ development [33]. Efforts should be driven toward the prevention of post-RT dental extraction both before and after RT. ...
Background: To evaluate factors associated with osteoradionecrosis of the jaw (ORNJ) in patients with head and neck squamous cell carcinoma (HNSCC), focusing on jaw-related dose-volume histogram (DVH) parameters.
Methods: We retrospectively reviewed the medical records of 616 patients with HNSCC treated with curative-intent or postoperative radiation therapy (RT) during 2008–2018. Patient-related (age, sex, history of smoking or alcohol use, diabetes mellitus, performance status, pre-RT dental evaluation, pre- or post-RT tooth extraction), tumor-related (primary tumor site, T-stage, nodal status), and treatment-related (pre-RT surgery, pre-RT mandible surgery, induction or concurrent chemotherapy, RT technique) variables and DVH parameters (relative volumes of the jaw exposed to doses of 10 Gy–70 Gy [V10–70]) were investigated and compared between patients with and without ORNJ. The Mann–Whitney U test was used to compare RT dose parameters. Univariate and multivariate Cox regression analyses were used to assess factors associated with ORNJ development. Kaplan–Meier analyses were performed for cumulative ORNJ incidence estimation.
Results: Forty-six patients (7.5%) developed ORNJ. The median follow-up duration was 40 (range, 3–145) months. The median time to ORNJ development was 27 (range, 2–127) months. DVH analysis revealed that V30-V70 values were significantly higher in patients with than in those without ORNJ. In univariate analyses, primary tumor site, pre-RT mandible surgery, post-RT tooth extraction, and V60 >14% were identified as important factors. In multivariate analyses, V60 >14% (p=0.0065) and primary tumor site (p=0.0059) remained significant. The 3-year cumulative ORNJ incidence rates were 2.5% and 8.6% in patients with V60 ≤14% and >14%, respectively (p<0.0001), and 1.4% and 9.3% in patients with oropharyngeal or oral cancer and other cancers, respectively (p<0.0001).
Conclusions: V60 >14%, and oropharyngeal or oral cancer were found to be independent risk factors for ORNJ. These findings might be useful to minimize ORNJ incidence in HNSCC treated with curative RT.
... A time period of 10-14 days is recommended between pre-RT extraction and irradiation [32]. Muraki et al. reported that dental interventions, including dental evaluation, prophylactic dental extraction, and good dental hygiene maintenance, both before and after RT have strong effects in the prevention of ORNJ development [33]. Efforts should be driven toward the prevention of post-RT dental extraction both before and after RT. ...
Background: To evaluate factors associated with osteoradionecrosis of the jaw (ORNJ) in patients with head and neck squamous cell carcinoma (HNSCC), focusing on jaw-related dose-volume histogram (DVH) parameters.
Methods: We retrospectively reviewed the medical records of 616 patients with HNSCC treated with curative-intent or postoperative radiation therapy (RT) during 2008–2018. Patient-related (age, sex, history of smoking or alcohol use, diabetes mellitus, performance status, pre-RT dental evaluation, pre- or post-RT tooth extraction), tumor-related (primary tumor site, T-stage, nodal status), and treatment-related (pre-RT surgery, pre-RT mandible surgery, induction or concurrent chemotherapy, RT technique) variables and DVH parameters (relative volumes of the jaw exposed to doses of 10 Gy–70 Gy [V10–70]) were investigated and compared between patients with and without ORNJ. The Mann–Whitney U test was used to compare RT dose parameters. Univariate and multivariate Cox regression analyses were used to assess factors associated with ORNJ development. Kaplan–Meier analyses were performed for cumulative ORNJ incidence estimation.
Results: Forty-six patients (7.5%) developed ORNJ. The median follow-up duration was 40 (range, 3–145) months. The median time to ORNJ development was 27 (range, 2–127) months. DVH analysis revealed that V30-V70 values were significantly higher in patients with than in those without ORNJ. In univariate analyses, primary tumor site, pre-RT mandible surgery, post-RT tooth extraction, and V60 >14% were identified as important factors. In multivariate analyses, V60 >14% (p=0.0065) and primary tumor site (p=0.0059) remained significant. The 3-year cumulative ORNJ incidence rates were 2.5% and 8.6% in patients with V60 ≤14% and >14%, respectively (p<0.0001), and 1.4% and 9.3% in patients with oropharyngeal or oral cancer and other cancers, respectively (p<0.0001).
Conclusions: V60 >14% and oropharyngeal or oral cancer were found to be independent risk factors for ORNJ. These findings might be useful to minimize ORNJ incidence in HNSCC treated with curative RT.
... The evidence of the efficacy of elimination of oral foci of infection to prevent postradiotherapy oral sequelae is growing (Beech et al., 2014;Eliyas et al., 2013;Jansma et al., 1992;Muraki et al., 2019;Schuurhuis et al., 2011Schuurhuis et al., , 2018Sennhenn-Kirchner et al., 2009), and in particular what to consider as an oral focus of infection in specific patient groups. We suggest, based on the literature, that the following should be considered as an oral focus of infection in HNC patients: ...
... Although no strict guidelines for preradiotherapy dental screening and elimination of oral foci exist, recent studies in HNC patients have shown that a strict execution of a dental screening protocol is mandatory (Bichsel, Lanfranchi, Attin, Grätz, & Stadlinger, 2016;Muraki et al., 2019;Schuurhuis et al., 2018). Not aggressively treating periodontally affected teeth preradiotherapy results in an increased risk for ORN, and patients with periodontal disease before IMRT are prone to develop bone healing problems after IMRT. ...
Pretreatment dental screening aims to locate and eliminate oral foci of infection in order to eliminate local, loco‐regional or systemic complications during and after oncologic treatment. An oral focus of infection is a pathologic process in the oral cavity that does not cause major infectious problems in healthy individuals, but may lead to severe local or systemic inflammation in patients subjected to oncologic treatment. As head and neck radiotherapy patients bear a lifelong risk on oral sequelae resulting from this therapy, the effects of chemotherapy on healthy oral tissues are essentially temporary and reversible. This has a large impact on what to consider as an oral focus of infection when patients are subjected to, e.g., head and neck radiotherapy for cancer or intensive chemotherapy for hematological disorders. While in patients subjected to head and neck radiotherapy oral foci of infection have to be removed before therapy that may cause problems ultimately, in patients that will receive chemotherapy such, so called chronic, foci of infection are not in need of removal of teeth but can be treated during a remission phase. Acute foci of infection always have to be removed before or early after onset of any oncologic treatment.
