The role of the endodontist in post irradiated patients: a case report
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1
Catholic University of the Sacred Heart, Rome, Department of Operative Dentistry and Endodontics, Italy
Introduction.
Osteoradionecrosis (ONG) of the jaws is considered the most severe long term adverse effect that can occur in the radiation therapy patient. Incidence of ONG has been stated to range from 2% as far as 20% and it has been reported that teeth extractions and dental diseases are the main risk factors for ONG in irradiated patients.
As a result, it is raccomended that a multidisciplinary team performs a pre-radiation dental screening to diagnose and treat caries, periodontal attachment loss, periapical problems and partially or completely impacted teeth to prevent oral complications.
Although opinion differs in litterature, it is advisable to perform dental extractions at least one year after radiotherapy.
Therefore, when post radiotherapy irreversible pulpitis or necrosis of the pulp occur, becouse of a missed pre-radiation dental screening or radio-induced caries, extractions should be avoided and, for restorable teeth, root canal treatment should be preferred instead.
The purpose of this case report is to show the role of the endodontist in irradiated patients. In the clinical case here described, two root canal therapies were performed on a post irradiated patient with a follow-up of six months, waiting to plan the extractions at a sufficient time distance.
Materials and Methods.
In October 2015, a 28-year-old man underwent tracheostomy, hemiglosectomy, pelvectomy, bilateral laterocervical lymph nodes dissection and reconstruction with anterolateral thigh (ALT) free flap because of diagnosis of keratinizing-type squamous cell carcinoma. As early as March 2016, a recurrence of oral carcinoma was diagnosed by magnetic resonance and subsequent biopsy.
The patient underwent surgery to remove recurrence of carcinoma of the oral cavity, revision of bilateral laterocervical lymph nodes dissection, tracheotomy and mandibular fibula free flap reconstruction. He was treated with radiotherapy at a dose of 66 Gy in 33 fractions delivered over 16 weeks.
Results.
After an oral and radiographic examination partially impacted mandibular decayed third molars and two deep carious lesions on 3.7 and 4.7 were found. Two root canal treatments were performed on the second mandibular molars even if an extraoral examination revealed a reduction of mouth opening (25 mm) due to head and neck radiotherapy. An access cavity was opened, the scouting was obtained with a K-file #10 (Dentsply Maillefer, Ballaigues, Switzerland) and the working lengths were assessed using an electronic apex locator (Dentaport ZX, J. Morita corporation, Tokyo, Japan). Instrumentation was carried out using Protaper Next system (Dentsply Maillefer, Ballaigues, Switzerland) and the apical preparations were performed with Verifier Files (Dentsply Maillefer, Ballaigues, Switzerland). The root canals were filled using AH Plus sealer (Dentsply DeTrey GmbH, Konstanz, Germany) and a single gutta-percha cone. Two direct resin composites were performed. No periapical radiographs were taken because of the lack of space between the teeth and the tongue and the total absence of depth of the mouth floor. During the post-operative observational period both teeth were asymptomatic. After seven month the digital panoramic radiography suggested an healty pariodontal legament around the teeth.
Discussion.
Patients who undergo radiotherapy can be subjected to several clinical problems. Their number has increased thanks to improvements in surgery and radiotherapy techniques and, consequently, more endodontists will be required in their multidisciplinary treatment. In this case report, the presence of partially impacted mandibular teeth and the limited buccal opening have greatly complicated the two root canal therapies, usually simple to perform. Although careful pre-radiation dental screening can partially avoid these situations, this clinical case showed the important role that the endodontist can play preventing the onset of post head and neck radiotherapy complications. Further prospective studies are necessary
to assess the outcome of root canal therapy in post irradiated patients and to evaluate this therapy as an alternative to tooth extraction.
References
1. Schuurhuis J.M., Stokman M.A., Roodenburg J.L., Reintsema H., Langendijk J.A., Vissink A., et al. (2011). Efficacy of routine pre-radiation dental screening and dental follow-up in head and neck oncology patients on intermediate and late radiation effects. A retrospective evaluation. Radiother. Oncol. 101, 403-409.
2. Store G., Boysen M. ( 2000). Mandibular osteoradionecrosis: clinical behaviour and diagnostic aspects. Clin. Otolaryngol. Allied. Sci. 25, 378-384.
3. Beech N., Robinson S., Porceddu S., Batstone M. (2014). Dental management of patients irradiated for head and neck cancer. Aust. Dent. J. 59, 20-28.
Keywords:
Endodontists,
Osteoradionecrosis,
Radiotheapy,
Root Canal Therapy,
OSCC (oral squamous cell carcinoma)
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:
Castagnola
R,
Minciacchi
I,
Rupe
C,
Marigo
L,
Grande
N and
Lajolo
C
(2019). The role of the endodontist in post irradiated patients: a case report.
Front. Physiol.
Conference Abstract:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine..
doi: 10.3389/conf.fphys.2019.27.00035
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Received:
01 Nov 2018;
Published Online:
09 Dec 2019.
*
Correspondence:
Dr. Raffaella Castagnola, Catholic University of the Sacred Heart, Rome, Department of Operative Dentistry and Endodontics, Roma, 00168, Italy, castagnolaraffaella@gmail.com