Dental Implants

Oral and dental complications from head and neck radiation therapy result from injury to the oral mucosa, salivary glands, bone surrounding teeth, taste buds, and oral musculature. The clinical manifestation is an increase in dental caries (cavities), worsening periodontal disease, xerostomia, loss of taste, difficulty and pain when opening the mouth, and mucosal irritation. The importance of proper dental screening prior to initiation of radiation therapy, and dental maintenance during and after completion of radiation therapy is discussed.

DENTAL SCREENING AND TREATMENT PRIOR TO STARTING RADIATION:

• An appointment with a general dentist is needed for a thorough exam to identify teeth with a hopeless prognosis, and to identify teeth that are in need of dental fillings or preventive care. It is important to have this appointment prior to starting radiation therapy.
• Typically, teeth that require extraction have the following characteristics: painful teeth, moderate to severe periodontal disease (loose teeth, bleeding gums, receding gum line), teeth with large fillings or have significant wear, and large cavities.
• Impacted teeth that are exposed to the oral cavity or expected to be in the direct line of radiation need extraction.
• Unopposed teeth that do not have contact from an opposing tooth require extraction.
• The dentist will be able to provide fillings and restorations on teeth that have a good long-term prognosis.
• The dentist will counsel you on short-term and long-term compliance.

DENTAL CARE DURING AND AFTER RADIATION THERAPY, INCLUDING LONG-TERM CARE — COMMON PROBLEMS AND TREATMENT OPTIONS:

It is important to maintain close surveillance with your general dentist. Appointments are typically every 3-6 months, or as necessary depending on symptoms.

1. It is of upmost importance to maintain good oral hygiene with brushing, flossing, and mouth rinses.
2. Xerostomia – Dry mouth, which is a common side effect of radiation therapy caused by damage to the salivary glands. Radiation therapy today strives to preserve that salivary glands therefore decreasing the severity of dry mouth. Dry mouth not only makes it more difficult to chew and swallow certain foods but also causes an increase in dental cavities. Treatments include maintaining adequate hydration and minimizing sugary drinks, using medications to promote salivary gland secretion, chewing sugarless gum, and using artificial saliva substitutes. ^1,3
3. Radiation Mucositis – Presents as ulcerations of oral mucosa and tongue and is often very painful. May involve any area of the mouth. Treatment includes supportive care and good oral hygiene needs to be upheld through this time to keep the bacterial load low and help prevent infections. ^1,3
4. Candidiasis (Oral Thrush) – White plaques that wipe off in your mouth. May also appear as reddish spots in your mouth and be painful. Commonly treated with antifungal mouth rinses and oral troches. Severe cases may require antifungal oral medication in pill form. ^1,3
5. Dental Cavities – There is an increase in cavity rate with radiation therapy, which is closely linked to the decrease in saliva production from the salivary glands, causing a more acidic environment within the mouth. Prevention of cavities involves a strict oral hygiene regimen. The dentist will perform routine cleanings and treat teeth with fluoride as necessary. Strict oral hygiene and regular follow ups with the dentist are key to prevention. ^1,3
6. Osteoradionecrosis – This is a rare but severe possible side effect of head and neck radiation therapy. The radiation affects the bone and blood vessels, decreasing the amount of blood and oxygen to bone. Causing the bone to break down and not repair itself. This process may initially present as some exposed bone within the mouth that does not heal and is commonly associated with tooth extractions after completion of radiation therapy. Extractions performed years after termination of radiation therapy are a potential cause. Mild cases of osteoradionecrosis may be treated with conservative treatment, while more advanced cases may require surgical correction. ²

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DENTAL IMPLANTS IN RADIATED PATIENTS

Some research suggests dental implants are more successful if placed before radiation therapy. The bone never fully recovers after radiation which likely reduces the success. Consider having dental implant placed during surgery to remove the tumor to have the highest chance of success.

References

1. Murdoch-Kinch CA, Zwetchkenbaum S. Dental Management of the Head and Neck Cancer Patient Treated with Radiation Therapy, 2011. J Mich Dent Assoc. 2011 93(7):28-37
2. Sultan A, et al. The Use of Hyperbaric Oxygen for the Prevention and Management of Osteoradionecrosis of the Jaw: A Dana-Farber/Brigham and Women’s Cancer Center Multidisciplinary Guideline, 2017. The Oncologist 2017 22:343-350
3. Vissink A, et al. Oral sequelae of head and neck radiotherapy, 2003. Crit Rev Oral Biol Med. 2003 14(3):199-212