Oral health of patients undergoing radiotherapy for head and neck cancer treatment: a Preliminary Report of a Prospective Observational clinical study.
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1
Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Department of Head and Neck, Italy
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2
Università Cattolica del Sacro Cuore, Department of Radiation Oncology , Italy
Aim. Head and neck squamous cell carcinoma (HNSCC) accounts for more than 600,000 new cases per year and its prognosis is still poor in terms of mortality and morbidity, as it causes approximately 350,000 deaths annually worldwide. Radiotherapy (RT) is an established treatment modality for HNSCC and other head and neck tumors, either for treatment alone or adjuvant. Unfortunately, high-dose RT has significant adverse effects on the oral and maxillofacial tissues, both hard and soft, among which osteoradionecrosis (ORN) is the most dangerous late adverse event, as it can be life-threatening; usually ORN is a clinical diagnosis and the most accepted definition accounts for irradiated necrotic bone, exposed through the overlying mucosa, without healing for 3 months, without recurrence of the tumor. Dental management of patients who should undergo RT for head and neck cancers can be crucial in the prevention of ORN onset, since tooth extractions seem to be the main risk factor. Few prospective studies have been performed to evaluate which teeth should be extracted, which extraction protocol should be used to minimize the risk and which other risk factors could contribute to the onset of ORN (i.e., site and timing of tooth extraction, surgical protocol, concomitant chemotherapy, oral hygiene status), thus dental management is mainly based on individual and expert opinions. The aim of this study is to evaluate the frequency of ORN in a patient cohort undergoing high dose RT for H&N cancer, receiving tooth extraction prior to RT.
Materials and Methods. The primary outcome of this study is to evaluate the incidence and the risk factors of ORN in a H&N cancer affected cohort undergoing radiotherapy and receiving tooth extraction prior to RT. The enrolled patients were visited before the beginning of RT, with the support of a panoramic radiograph. An evaluation of their oral health was made and any recommended tooth extraction was completed before the beginning of RT. A tooth was considered to be extracted if one or more of the following pathological conditions was detected: impacted third molars with radiographic sign of pericoronitis, teeth with periapical lesion which had already been endodontically treated, unrestorable teeth, periodontally compromised teeth affected by one of the following (periodontal probing depth ≥ 5 mm, clinical attachment level ≥ 8 mm, grade 2 tooth mobility, II grade furcation involvement). An antibiotic prophylaxis and therapy with amoxicillin (875 mg) and clavulanic acid (125mg) bid for five days, starting the day before tooth extraction and chlorhexidine 0.12% rinses bid for 15 days, starting the day before tooth extraction, were prescribed. Furthermore, an interval of 15 days between the last tooth extraction and the beginning of RT was recommended. Follow-up visits were conducted at 15 days, 1, 3, 6 and 12 months after the beginning of RT.
Results. In one year of clinical activity, 87 patients, who underwent RT for head and neck cancer were visited: among these, 56 patients required at least a tooth extraction and, among these, 6 patients dropped out, so a total of 50 patients were finally enrolled. 27 patients received a 6 months follow up and 23 a 3 months follow-up. 256 teeth were extracted (mean 5,1 for patient), 3 of which resulted in a Osteoradionecrosis, in 3 different patients. All the ORN cases involved the mandibular bone, two of them regarded the socket of a removed impacted third molar and both patients received adjuvant chemotherapy. All the ORN healed after a medical therapy based on antibiotic therapy and chlorhexidine 0.2% professional socket irrigation.
Discussion. Tooth extraction has been recognized as a risk factor for the development of ORN, especially in the posterior area of the lower jaw. In the preliminary results of our study and within its limitations, we developed 3 osteonecrosis in 256 extractions and the major risk factors were the surgical site (posterior mandible) and the association with chemotherapy. Nevertheless, a good medical therapy together with a strict follow-up of the patients allowed to solve the ORNs. Since ORN can be a late onset complication of RT, a longer follow-up must be performed to draw definitive conclusions.
References
1. Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, Heaivilin N, Zumsteg ZS. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017 Dec;6(12):2918-2931. doi: 10.1002/cam4.1221. Epub 2017 Oct 25. Review. PubMed PMID: 29071801; PubMed Central PMCID: PMC5727249.
2. Nabil S, Samman N. Risk factors for osteoradionecrosis after head and neck radiation: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 Jan;113(1):54-69. doi: 10.1016/j.tripleo.2011.07.042. Epub 2012 Feb 3. Review.
3. Notani K, Yamazaki Y, Kitada H, Sakakibara N. H, Fukuda, K. Omori, M. Nakamura, Management of mandibular osteoradionecrosis corresponding to the severity of osteoradionecrosis and the method of radiotherapy Head Neck. 2003;25:181–186. doi: 10.1002/hed.10171
Keywords:
Radiotherapy,
Osteoradionecrosis,
Tooth extractions,
head and neck cancer,
chemotherapy
Conference:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine., Ancona, Italy, 19 Oct - 20 Oct, 2018.
Presentation Type:
Poster Presentation
Topic:
Oral Diseases
Citation:
Lajolo
C,
Rupe
C,
Gioco
G,
Paludetti
G,
Miccichè
F and
Cordaro
M
(2019). Oral health of patients undergoing radiotherapy for head and neck cancer treatment: a Preliminary Report of a Prospective Observational clinical study..
Front. Physiol.
Conference Abstract:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine..
doi: 10.3389/conf.fphys.2019.27.00072
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Received:
05 Nov 2018;
Published Online:
09 Dec 2019.
*
Correspondence:
Prof. Carlo Lajolo, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Department of Head and Neck, Rome, Lazio, 00168, Italy, fedemurkez@gmail.com