Special Care Instructions for Radiation Patients

GUIDELINES FOR DENTAL EXTRACTIONS BEFORE HEAD AND NECK RADIATION THERAPY

At the University of Florida Oral Oncology Clinic, recommendations for dental extractions prior to the initiation of radiation therapy include but are not limited to the following list of factors. Extractions prior to head and neck radiation are often recommended to reduce the risk of osteonecrosis of the jaws after radiation.

NON-DENTAL FACTORS
*Radiation dose
If the radiation dose to the bone of the mandible and maxilla is less than 5000cGy, then according to the literature and our experience, there should be minimal risk of osteonecrosis after radiotherapy. The radiation oncologist must give this information to the dentist prior to the initiation of head and neck radiation.

*Location of radiation ports
At the UF Oral Oncology Clinic, recommendations for dental extractions prior to radiotherapy are limited to those areas of the mandible and maxilla that are going to receive greater than 5000cGy. The radiation oncologist must give this information to the dentist prior to the initiation of head and neck radiation. If there are teeth outside of the potential high dose field of radiation that are symptomatic or have a hopeless prognosis, they should be extracted prior to radiation, if time permits.

*Patient prognosis
If the prognosis of the patient is extremely poor or if the tumor is growing rapidly, the radiation oncologist may decide that radiation needs to proceed without delay. After extraction, 2-3 weeks healing time is recommended before head and neck radiation therapy begins.

*Patient age
The younger the patient, the longer the teeth must be maintained disease free. If dental extractions are required (due to tooth decay or periodontal disease) in areas that will receive high dose radiation, the patient will be at significant risk for osteonecrosis. The risk of osteonecrosis in irradiated areas is present for the duration of the patient's life. There is no "safe" time limit to wait for extractions or surgery in these areas. Therefore, the patient needs to be informed of the potential life-long risk before radiation therapy is initiated, even if the teeth are very healthy.

*Patient finances
If the patient cannot afford dental care that is required after radiation therapy, serious consideration needs to be given as to whether any teeth should remain in the proposed high dose field of radiation.

*Patient compliance
If the patient has demonstrated lack of motivation in previous dental care and oral hygiene, or has a severe dental phobia, serious consideration needs to be given whether any teeth should remain in the proposed high dose field of radiation.

DENTAL FACTORS

*Radiographs
A panoramic radiograph should be taken prior to radiotherapy to assess health of the teeth and jaws. Patients without teeth should also have a panoramic film. Other intraoral radiographs may be necessary.

*Periodontal disease
Teeth in the proposed high dose field of radiation should be considered for preradiation therapy extraction if periodontal sulcular depths are equal to or greater than 5mm, if there is furcation involvement, if they have a history of refractory periodontitis, tooth mobility, bleeding, or inflammation of the gums.

*Caries (tooth decay)
Teeth in the proposed high dose field of radiation should be considered for preradiation therapy extraction if they have deep decay, especially in a patient that has numerous areas of tooth decay throughout the oral cavity.

*Root canals
Teeth having root canals in the proposed high dose field of radiation should be considered for preradiation therapy extraction if they have silver points and/or evidence of root canal failure, i.e. pain, swelling or apical radiolucencies.

*Impactions
Impacted teeth, especially third molars, that will be located in the proposed high dose field of radiation should be extracted prior to radiation, if there is pathology associated with the teeth or if the teeth have a communication with the oral cavity.

*Large fillings, fractures, occlusal wear
Teeth with large fillings, fractures or significant occlusal wear should be considered for extraction prior to receiving high dose radiotherapy.

*Pain, apical radiolucency
Teeth that are painful, have a history of pain, sensitivity to percussion or apical radiolucency should be considered for extraction prior to receiving high dose radiotherapy.

*Unopposed teeth
Teeth that do not have contact with a tooth in the opposing arch should be considered for extraction prior to receiving high dose radiotherapy, if they are in the proposed high dose radiation field.

SURGICAL GUIDELINES FOR EXTRACTIONS PRIOR TO HEAD AND NECK RADIATION THERAPY

*Perform adequate alveoloplasty with extractions to eliminate sharp bony projections, tori and to make the patient "denture ready".

*Achieve primary closure, if possible. Do not stretch the mucosal tissue beyond its physiologic limits.

*It may be advisable to place the patient on prophylactic antibiotics for one week after extraction to reduce the risk of infection.

*Allow a minimum of 14-21 days of healing prior to the initiation of radiation therapy.