Dental status, dental treatment procedures and radiotherapy as risk factors for infected osteoradionecrosis (IORN) in patients with oral cancer – a comparison of two 10 years’ observation periods

Abstract

ObjectivesDental status, dental treatment procedures and radiotherapy dosage as potential risk factors for an infected osteoradionecrosis (IORN) in patients with oral cancers: Retrospective evaluation of 204 patients treated in two observation periods of approximately ten years each.Patients and methodsIn group A, 90 patients were treated in the years 1993-2003, in group B 114 patients in the years 1983-1992 (data in brackets). All patients had histopathologically proven squamous cell cancers, mainly UICC stages III and IV. 70% (85%, n.s.) had undergone surgery before radiotherapy. All patients were referred to the oral and maxillofacial surgeon for dental rehabilitation before further treatment.Radiotherapy was performed using a 3D-conformal technique with 4-6MV photons of a linear accelerator (Co-60 device up to 1987). The majority of patients were treated using conventional fractionation with total doses of 60-70 Gy in daily fractions of 2 Gy. Additionally, in group A, hyperfractionation was used applying a total dose of 72 Gy in fractions of 1.2 Gy twice daily (time interval > 6 hours). In group B, a similar schedule was used up to a total dose of 82.8 Gy (time interval 4-6 hours). 14 (0) patients had radiochemotherapy simultaneously. After therapy, the patients were seen regularly by the radiooncologist and – if necessary – by the oral and maxillofacial surgeon. The duration of follow-up was 3.64 years (5 years, p = 0.004).ResultsBefore radiotherapy, the dental health status was very poor. On average, 21.5 (21.2, n.s.) teeth were missing. Further 2.04 teeth (2.33, n.s.) were carious, 1.4 (0.3, p = 0.002) destroyed.Extractions were necessary in 3.6 teeth (5.8, p = 0.008), conserving treatment in 0.4 (0.1, p = 0.008) teeth. After dental treatment, 6.30 (4.8, n.s.) teeth remained.IORN was diagnosed after conventionally fractionated radiotherapy in 15% (11%, n.s.), after hyperfractionation in 0% (34%, p = 0.01).ConclusionWithin more than 20 years there was no improvement in dental status of oral cancer patients. Extensive dental treatment procedures remained necessary. There was an impressive reduction of the IORN frequency in patients treated in a hyperfractionated manner probably resulting from a dose reduction and an extension of the interfraction time.

Radiotherapy‐induced oral morbidities in head and neck cancer patients

“…Numerous pre‐ and postirradiation factors (alone or in combination) may predispose the patients to ORN. Cumulative radiation dose of greater than 60 Gy, increased numbers of fractions at higher doses, surgical wound related to tooth extraction, inadequate healing time between pre‐RT surgery (extractions, peri‐radicular surgery) to start of RT (less than 2‐3 weeks), poor oral hygiene, active periodontal disease, persistent and untreated periapical pathology, trauma due to ill‐fitting prosthesis, nutritionally depleted and immune‐compromised patient, proximity of tumor and bone, and dense and compact nature of the bone 77‐84 …”

A Study of the Experience of German Dental Practitioners with Patients on Bisphosphonates or Anticoagulants

“…Notably, all cancer patients having participated in the study (100 percent) had a preventive examination (100 percent) and most (70percent) had two. Fig.3 shows the number of extracted teeth (11) in the group of 20 patients treated during anticoagulant therapy. Analysis reveals that three patients had 1 tooth extracted, one had 2 teeth extracted, and two had 3 teeth extracted.…”

“…In case surgery is required during drug intake, specific rules are to be followed. A possible complication is bisphosphonate-related osteonecrosis of the jaw (BRONJ) manifesting as exposed, nonvital bone that does not recover over 8 weeks after current or past bisphosphonate therapy (6,7,8,9,10,11,12) The mains steps included in the Germany clinical protocol for dental sanitation and care in patients receiving or planned to receive bisphosphonate therapy are as follows: (13,14,15)…”

A culture shock in dental hygiene: Exploring the management of oral health after head and neck cancer

“…There is a tendency for HNC patients to report a history of infrequent dental attendance and dental problems that consequently require management prior to beginning cancer treatment. Previous studies of oral health among HNC patients focus on cancer outcomes, management protocols 23,24 or describe the impact of oral symptoms on quality of life. 17 Despite this, and the increased threat to maintaining a functioning dentition caused by the treatment for HNC, supportive oral health care is comparatively under-researched.…”

“…17 Despite this, and the increased threat to maintaining a functioning dentition caused by the treatment for HNC, supportive oral health care is comparatively under-researched. Previous studies of oral health among HNC patients focus on cancer outcomes, management protocols 23,24 or describe the impact of oral symptoms on quality of life. 19,20,25 This study aimed to understand the post-HNC management of oral health, exploring factors that influenced oral health behaviours and oral healthcare utilization from the patient perspective.…”