Published: May 2003
Dental Recall/Restorative Treatment
Following completion of all radiation therapy and resolution of the acute oral side effects, the patient should be placed on a dental recall schedule at intervals appropriate to the maintenance of excellent oral status. A typical recall frequency for prophylaxis and home care evaluation may be every four to eight weeks for the first six months following radiation therapy. The frequency of recall visits should be adjusted according to the needs of the individual patient.
Perform restorative dental procedures as needed. Consideration should be given to the use of glass ionomer and resin-bonded restoration of remineralized tooth structure. The prophylactic bonding of sealant resins to remineralized tooth structure may be beneficial. (See next section on remineralizing gels). For the pediatric patient, consideration should be given to restoration with stainless steel crowns.
Control of Demineralization/Patient Home Care
Patients may believe that, over time, saliva levels have recovered. However, it is well documented that the quantity and/or quality of saliva is typically permanently compromised and never recovers to normal values. Therefore
fluoride gel applications must be continued at a frequency sufficient to maintain tooth mineralization. This may require lifelong daily application(s) of either a 1.1% neutral sodium fluoride or a 0.4% stannous fluoride. A neutral pH fluoride should be used by patients with porcelain crowns.
For patients with early or persistent enamel breakdown, remineralization of teeth may be achieved by regular application of a calcium phosphate remineralizing gel in gel-applicator trays. Applications are made after tooth cleansing procedures have been completed. In the severely xerostomic patient, these procedures should be completed after every meal and before retiring to bed, in addition to a daily fluoride application. Frequency can rarely be reduced because xerostomia is usually lifelong. Patients with enamel breakdown, but who demonstrate compliance with oral hygiene procedures and gel applications, may need a dietary analysis to assist with the elimination of cariogenic foods or oral medications. Chlorhexidine products may help control cariogenic bacterial plaque.
Continue assistance with the palliative management of xerostomia and the identification and treatment of oral infections.
Monitor patient for evidence of trismus. Encourage daily jaw exercises.
Prosthodontics
Prosthodontic appliances may be constructed after the mucositis has resolved and integrity of the oral tissues has been reestablished.
Appliances must be carefully adjusted to prevent tissue irritation and the initiation of soft or hard tissue necrosis.
Some patients may never re-acquire the ability to tolerate a tissue-borne prostheses because of friable tissues and xerostomia.
For the comprehensive management of major dental breakdown, or of significant prosthetic need, referral to a maxillofacial prosthodontist with experience in the treatment of cancer patients is indicated when possible.
Oral Surgery
Invasive surgical procedures involving exposure of irradiated bone should be avoided if at all possible, due to risk for osteoradionecrosis. If tooth extraction is unavoidable, extreme caution must be exercised. Conservative surgical technique, antibiotic coverage for at least two weeks post-operatively, and the use of hyperbaric oxygen therapy for tissue preparation may all be essential to assure complete healing. Alternatives to tooth extraction include coronal amputation and root canal therapy
Children
Following radiation therapy to the craniofacial and dental structures, children should be closely monitored by a dental specialist in growth and development.
