1. GOOD MORNINGGOOD MORNING www.indiandentalacademy.comwww.indiandentalacademy.com

2. Dental management of aDental management of a Radiation TherapyRadiation Therapy PatientPatient INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com 3. CONTENTSCONTENTS INTRODUCTIONINTRODUCTION TREATMENT RATIONALETREATMENT RATIONALE DENTAL EXAMINATIONDENTAL EXAMINATION PRE RADIATION CAREPRE RADIATION CARE DENTAL CARE DURING THE THERAPYDENTAL CARE DURING THE THERAPY POST RADIATION CAREPOST RADIATION CARE PROSTHODONTIC CONSIDERATIONSPROSTHODONTIC CONSIDERATIONS CONCLUSIONCONCLUSION REFERENCESREFERENCES www.indiandentalacademy.comwww.indiandentalacademy.com 4. IntroductionIntroduction Role of Prosthodontist in improving qualityRole of Prosthodontist in improving quality of head and neck cancer patients is wellof head and neck cancer patients is well recognized.recognized. Prior to the early 1960s: Ablative surgeryPrior to the early 1960s: Ablative surgery Challenged with the task of developingChallenged with the task of developing treatment regimes for the oraltreatment regimes for the oral complications associated with radiationcomplications associated with radiation therapy.therapy. www.indiandentalacademy.comwww.indiandentalacademy.com 5. National institute of Health noted in aNational institute of Health noted in a consensus development statement :consensus development statement : At a minimum, oral complications are painful,At a minimum, oral complications are painful, diminish the quality of life, and lead todiminish the quality of life, and lead to significant compliance problems, oftensignificant compliance problems, often discouraging patient from treatmentdiscouraging patient from treatment Significance of the need of a dentalSignificance of the need of a dental oncologistoncologist www.indiandentalacademy.comwww.indiandentalacademy.com 6. Principles of radiation therapyPrinciples of radiation therapy Radiation therapy is defined as theRadiation therapy is defined as the therapeutic use of ionizing radiation.therapeutic use of ionizing radiation. Types:Types: Electromagnetic (photon) radiationElectromagnetic (photon) radiation X-raysX-rays Gamma RaysGamma Rays Particulate radiationParticulate radiation www.indiandentalacademy.comwww.indiandentalacademy.com 7. Cell DeathCell Death Reproductive cell death Interphase (Direct) cell death www.indiandentalacademy.comwww.indiandentalacademy.com 8. Treatment rationaleTreatment rationale Preventing the risk of infection duringPreventing the risk of infection during active phase of chemotherapyactive phase of chemotherapy Reducing the potential for both short term-Reducing the potential for both short term- and long term problems in the irradiatedand long term problems in the irradiated patient.patient. www.indiandentalacademy.comwww.indiandentalacademy.com 9. Ideally, the dental examination and theIdeally, the dental examination and the necessary dental treatment should benecessary dental treatment should be performed prior to the onset of theperformed prior to the onset of the definitive cancer treatment.definitive cancer treatment. Complete co-operation from theComplete co-operation from the physician oncologist.physician oncologist. www.indiandentalacademy.comwww.indiandentalacademy.com 10. MucositisMucositis XerostomiaXerostomia Change in oralChange in oral microfloramicroflora Loss of tasteLoss of taste Increased sensitivityIncreased sensitivity to spicy or strongto spicy or strong tasting foodstasting foods Reduced potential forReduced potential for bone healingbone healing Risk of developingRisk of developing osteoradionecrosisosteoradionecrosis Trismus (muscularTrismus (muscular fibrosis)fibrosis) SHORT TERM EFFECTS LONG TERM EFFECTS www.indiandentalacademy.comwww.indiandentalacademy.com 11. Understanding the Oral OncologyUnderstanding the Oral Oncology patientpatient Dentists role:Dentists role: Gain patients confidenceGain patients confidence Establish a position as an informationEstablish a position as an information sourcesource Explain the causes of concernExplain the causes of concern Emphasize the importance of totalEmphasize the importance of total commitment to the treatment regimenscommitment to the treatment regimens proposed.proposed. The initial dental appointmentThe initial dental appointment www.indiandentalacademy.comwww.indiandentalacademy.com 12. Make the patient have a basicMake the patient have a basic understanding of the long and shortunderstanding of the long and short term effects of radiation therapy.term effects of radiation therapy. www.indiandentalacademy.comwww.indiandentalacademy.com 13. Dental Examination andDental Examination and Treatment PlanTreatment Plan Full-mouth or panoramic radiographsFull-mouth or panoramic radiographs Comprehensive clinical examinationComprehensive clinical examination periodontiumperiodontium oral soft tissuesoral soft tissues Assessment of the patient's oralAssessment of the patient's oral hygienehygiene Examine carefully for dental cariesExamine carefully for dental caries www.indiandentalacademy.comwww.indiandentalacademy.com 14. Perform Dental prophylaxisPerform Dental prophylaxis Review oral hygiene proceduresReview oral hygiene procedures Place Definitive restorationsPlace Definitive restorations Teeth considered non restorable orTeeth considered non restorable or non salvageable with endodonticnon salvageable with endodontic therapy should be extracted.therapy should be extracted. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 15. Healing period of atleastHealing period of atleast 10 days to10 days to 3 weeks3 weeks is essential before radiationis essential before radiation treatment begins.treatment begins. Proposed extractions must be discussedProposed extractions must be discussed with the radiation oncologist and anwith the radiation oncologist and an understanding readied regarding the timeunderstanding readied regarding the time available for healing.available for healing. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 16. When surgical removal of a tumor isWhen surgical removal of a tumor is planned prior to radiation, teeth can beplanned prior to radiation, teeth can be conveniently removed in the operatingconveniently removed in the operating room at the time of tumor surgery, thusroom at the time of tumor surgery, thus ensuring an adequate healing period.ensuring an adequate healing period. Teeth be removedTeeth be removed withwith minimal traumaminimal trauma and the extraction sites beand the extraction sites be closedclosed primarilyprimarily.. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 17. Antibiotic coverage may improve theAntibiotic coverage may improve the potential for healing in the case ofpotential for healing in the case of diabetics and other medicallydiabetics and other medically compromised individuals.compromised individuals. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 18. To Extract or not to ExtractTo Extract or not to Extract Following radiation treatment:Following radiation treatment: Increased risk of osteoradionecrosisIncreased risk of osteoradionecrosis Wound healing compromisedWound healing compromised Extensive periodontal surgery contraindicatedExtensive periodontal surgery contraindicated Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 19. Periodontally involved teeth exhibiting moderatePeriodontally involved teeth exhibiting moderate to severe mobility should also be considered forto severe mobility should also be considered for removal.removal. Some thought must be given to the long-termSome thought must be given to the long-term prognosis of the teeth in question.prognosis of the teeth in question. The patient's ability and willingness to performThe patient's ability and willingness to perform all recommended oral hygiene procedures willall recommended oral hygiene procedures will also help determine which teeth can bealso help determine which teeth can be maintained.maintained. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 20. In questionable situations, it isIn questionable situations, it is perhaps more prudent to err on theperhaps more prudent to err on the side of aggressive tooth removalside of aggressive tooth removal Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 21. Decision to extract all remainingDecision to extract all remaining teethteeth Patient rendered completely edentulousPatient rendered completely edentulous with no previous denture experience maywith no previous denture experience may find the process of adjusting to completefind the process of adjusting to complete dentures a difficult one.dentures a difficult one. Soft tissues within the radiated field will beSoft tissues within the radiated field will be easily irritated by the prosthesis.easily irritated by the prosthesis. Lack of salivaLack of saliva Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 22. Consider maintaining strategically positioned,Consider maintaining strategically positioned, periodontally sound teeth to be used asperiodontally sound teeth to be used as abutments for removable partial dentures orabutments for removable partial dentures or complete overdenturescomplete overdentures Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 23. Radical alveolectomiesRadical alveolectomies Removal of tori and exostosesRemoval of tori and exostoses Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 24. Partially erupted or impactedPartially erupted or impacted third molarsthird molars Amount of time the physician oncologist is willingAmount of time the physician oncologist is willing to allow for healing.to allow for healing. Impactions requiring extensive bone removalImpactions requiring extensive bone removal may take longer to heal and are at greater riskmay take longer to heal and are at greater risk for infection, necessitating a possible delay infor infection, necessitating a possible delay in the start of the radiation treatment.the start of the radiation treatment. These extractions may be a greater problem inThese extractions may be a greater problem in the older, physically compromised individualthe older, physically compromised individual compared with a younger, healthier patient.compared with a younger, healthier patient. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 25. Since the fully impacted tooth does notSince the fully impacted tooth does not precipitate many major, immediateprecipitate many major, immediate problems following radiation, the decisionproblems following radiation, the decision to extract or not extract these teeth canto extract or not extract these teeth can only be reached after careful review of allonly be reached after careful review of all factors.factors. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 26. Partially erupted teethPartially erupted teeth previous episodes of pericoronal infectionsprevious episodes of pericoronal infections Following radiation:Following radiation: Trismus will limit accessTrismus will limit access Surgery will result in a risk of compromisedSurgery will result in a risk of compromised wound healingwound healing It is certainly an advantage to extract theseIt is certainly an advantage to extract these partially erupted teeth prior to radiation.partially erupted teeth prior to radiation. Diagnosis & treatment plan www.indiandentalacademy.comwww.indiandentalacademy.com 27. Pre Radiation ProsthodonticPre Radiation Prosthodontic CareCare In case of previous denture wearers,In case of previous denture wearers, regardless of the condition of theregardless of the condition of the dentures, little definitive prosthodonticdentures, little definitive prosthodontic care is necessary prior to radiation.care is necessary prior to radiation. Severity of resulting mucositisSeverity of resulting mucositis Substantial weight lossSubstantial weight loss www.indiandentalacademy.comwww.indiandentalacademy.com 28. There is little advantage to relining ill-There is little advantage to relining ill- fitting dentures since the procedure canfitting dentures since the procedure can be moderately expensive and will not bebe moderately expensive and will not be a factor in patient comfort during variousa factor in patient comfort during various stages of mucositis.stages of mucositis. Soft, temporary reline materials, becauseSoft, temporary reline materials, because of their surface porosity andof their surface porosity and abrasiveness, make hygiene proceduresabrasiveness, make hygiene procedures difficult, serve as a potential reservoir fordifficult, serve as a potential reservoir for fungal growth, and may be a source offungal growth, and may be a source of additional mucosal discomfort.additional mucosal discomfort. Pre Radiation care www.indiandentalacademy.comwww.indiandentalacademy.com 29. All these factors warrant the fabricationAll these factors warrant the fabrication of new dentures once radiation therapyof new dentures once radiation therapy is complete.is complete. Pre Radiation care www.indiandentalacademy.comwww.indiandentalacademy.com 30. Patients are advised that they will bePatients are advised that they will be better served by not wearingbetter served by not wearing denturesdentures during therapy.during therapy. The patient must be cautioned thatThe patient must be cautioned that continuing to wear the dentures maycontinuing to wear the dentures may be the source of significant additionalbe the source of significant additional mucosal irritation and lead to delayedmucosal irritation and lead to delayed healing following the completion ofhealing following the completion of radiation therapy.radiation therapy. Pre Radiation care www.indiandentalacademy.comwww.indiandentalacademy.com 31. Dentate patients with metallic crowns orDentate patients with metallic crowns or fixed partial dentures in the treatment fieldfixed partial dentures in the treatment field may suffer significant irritation to adjacentmay suffer significant irritation to adjacent soft tissue as a result of backscatter.soft tissue as a result of backscatter. Use of shieldUse of shield Pre Radiation care www.indiandentalacademy.comwww.indiandentalacademy.com 32. An increasing number of patients withAn increasing number of patients with dental implants are being seen atdental implants are being seen at treatment centers. Much controversytreatment centers. Much controversy exists regarding the need to remove theexists regarding the need to remove the implants before radiation.implants before radiation. Pre Radiation care www.indiandentalacademy.comwww.indiandentalacademy.com 33. Dental Management DuringDental Management During Radiation TherapyRadiation Therapy MucositisMucositis Loss of tasteLoss of taste Xerostomia and Dental cariesXerostomia and Dental caries Trismus and FibrosisTrismus and Fibrosis Shielding and Positioning stentsShielding and Positioning stents www.indiandentalacademy.comwww.indiandentalacademy.com 34. MucositisMucositis One of the earliest effects of radiationOne of the earliest effects of radiation www.indiandentalacademy.comwww.indiandentalacademy.com 35. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 36. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 37. Acute mucositis begins during the second or third week of radiation therapy and subsides within 8 to 10 weeks once treatment is completed. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 38. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 39. Resulting pain and dysphagia make it difficult forResulting pain and dysphagia make it difficult for the patient to eat a well balanced diet, resultingthe patient to eat a well balanced diet, resulting in what may be a significant weight loss. It mayin what may be a significant weight loss. It may be necessary to interrupt therapy if the weightbe necessary to interrupt therapy if the weight loss becomes critical.loss becomes critical. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 40. Severity of the mucositis is influenced by aSeverity of the mucositis is influenced by a number of factors and is not alwaysnumber of factors and is not always predictable. Patients with a history ofpredictable. Patients with a history of alcohol abuse or smoking, for example,alcohol abuse or smoking, for example, who continue these habits during radiationwho continue these habits during radiation suffer the greatest morbidity.suffer the greatest morbidity. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 41. Methods to help alleviate theMethods to help alleviate the patients discomfortpatients discomfort Most significant being good oral hygieneMost significant being good oral hygiene (Flemming 1990)(Flemming 1990) Frequent daily cleaning of the teeth with aFrequent daily cleaning of the teeth with a soft brush and mild tasting toothpaste.soft brush and mild tasting toothpaste. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 42. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 43. Frequent oral rinses with aFrequent oral rinses with a combination ofcombination of salt and sodium bicarbonate in water orsalt and sodium bicarbonate in water or dilute solutions of hydrogen peroxide anddilute solutions of hydrogen peroxide and waterwater Other therapies have included rinsing withOther therapies have included rinsing with Benadryl elixirs, sucrafate solutions, andBenadryl elixirs, sucrafate solutions, and topicaltopical anesthetics.anesthetics. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 44. MucositisMucositis www.indiandentalacademy.comwww.indiandentalacademy.com 45. Loss of tasteLoss of taste Occurs rapidly during the first week or two ofOccurs rapidly during the first week or two of treatmenttreatment Gradually returns to normal once the treatmentGradually returns to normal once the treatment course is completed.course is completed. Possible contributing factors:Possible contributing factors: Damage to taste buds and microvilliDamage to taste buds and microvilli Disrupted innervation as a result of the radiationDisrupted innervation as a result of the radiation Lack of salivaLack of saliva Additional cause of weight loss during therapy.Additional cause of weight loss during therapy. www.indiandentalacademy.comwww.indiandentalacademy.com 46. XerostomiaXerostomia Changes in the quantity and quality of salivaChanges in the quantity and quality of saliva as a result of radiation have beenas a result of radiation have been documented in the dental literature (Brown etdocumented in the dental literature (Brown et al, 1978).al, 1978). www.indiandentalacademy.comwww.indiandentalacademy.com 47. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 48. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 49. Beginning withBeginning with the first course ofthe first course of treatment,treatment, salivary flow ratessalivary flow rates decrease,decrease, eventuallyeventually reaching as lowreaching as low as 1% of normal.as 1% of normal. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 50. www.indiandentalacademy.comwww.indiandentalacademy.com 51. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 52. The patient experiences a need toThe patient experiences a need to continually lubricate the mouth and iscontinually lubricate the mouth and is forced to ingest large quantities of fluid toforced to ingest large quantities of fluid to aid in swallowing at mealtimes.aid in swallowing at mealtimes. There is a disconcerting change in eatingThere is a disconcerting change in eating habits with an increased intake of soft,habits with an increased intake of soft, moist foods.moist foods. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 53. Food debris accumulates on the oralFood debris accumulates on the oral mucosa and teeth because of themucosa and teeth because of the absence of theabsence of the self-cleansing actionself-cleansing action of saliva, making oral hygiene muchof saliva, making oral hygiene much more difficult.more difficult. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 54. Attempts have been made to stimulateAttempts have been made to stimulate salivary flow rates with sialogogues such assalivary flow rates with sialogogues such as pilocarpine and antholetrithione (Fox et al,pilocarpine and antholetrithione (Fox et al, 1986).1986). There is no concrete evidence that the drugsThere is no concrete evidence that the drugs are effective in those individuals receivingare effective in those individuals receiving high doses of radiation to all major salivaryhigh doses of radiation to all major salivary glands.glands. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 55. Saliva substitutes have been developed inSaliva substitutes have been developed in an effort to alleviate the discomfort andan effort to alleviate the discomfort and harmful effects of xerostomia.harmful effects of xerostomia. These products consist primarily ofThese products consist primarily of carboxymethylcellulose with various saltscarboxymethylcellulose with various salts and flavoring agents added.and flavoring agents added. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 56. Results with the use of the substitutes areResults with the use of the substitutes are mixed, related more to the subjectivemixed, related more to the subjective preference of the patient than to anypreference of the patient than to any appreciable therapeutic effect.appreciable therapeutic effect. XerostomiaXerostomia www.indiandentalacademy.comwww.indiandentalacademy.com 57. Along with xerostomia, there is aAlong with xerostomia, there is a concomitant increase in the numbers ofconcomitant increase in the numbers of acidogenic and cariogenicacidogenic and cariogenic microorganisms and a decrease inmicroorganisms and a decrease in noncariogenic microorganisms resulting innoncariogenic microorganisms resulting in a severe, aggressive form of dental caries.a severe, aggressive form of dental caries. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 58. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 59. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 60. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 61. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 62. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 63. The most effective method of treating thisThe most effective method of treating this condition was through the daily use of topicalcondition was through the daily use of topical applications of fluoride (Dreizen et al, 1977).applications of fluoride (Dreizen et al, 1977). Both stannous or sodium fluoride have beenBoth stannous or sodium fluoride have been used in a variety of forms (gels, rinses, andused in a variety of forms (gels, rinses, and toothpastes) with significant success.toothpastes) with significant success. Gels used with a tray are reported to betterGels used with a tray are reported to better cover all tooth surfaces than either fluoridecover all tooth surfaces than either fluoride rinses or gels applied with a brush.rinses or gels applied with a brush. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 64. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 65. Neutral sodium fluoride preferred over stannous fluoride which can be more irritating. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 66. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 67. The use of a tray as a carrier simplifies theThe use of a tray as a carrier simplifies the fluoride application procedure andfluoride application procedure and improves patient compliance, achieving aimproves patient compliance, achieving a better overall effect.better overall effect. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 68. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 69. Patients must be made to understand thatPatients must be made to understand that they will need to use fluoride once a day,they will need to use fluoride once a day, every day for the remainder of their lives.every day for the remainder of their lives. Discontinuing the fluoride applications,Discontinuing the fluoride applications, even for short periods of time, may resulteven for short periods of time, may result in renewed cariogenic activity.in renewed cariogenic activity. Radiation cariesRadiation caries www.indiandentalacademy.comwww.indiandentalacademy.com 70. Trismus and FibrosisTrismus and Fibrosis Begins shortly after radiation begins.Begins shortly after radiation begins. Clinically, the patient gradually loses the abilityClinically, the patient gradually loses the ability to open the mouth.to open the mouth. The condition may be exacerbated by surgeryThe condition may be exacerbated by surgery prior to radiation and by radiation fields whichprior to radiation and by radiation fields which include muscle of mastication or the TMJ.include muscle of mastication or the TMJ. www.indiandentalacademy.comwww.indiandentalacademy.com 71. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 72. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 73. It may make eating difficult and theIt may make eating difficult and the performance of dental procedures almostperformance of dental procedures almost impossible.impossible. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 74. Primary treatmentPrimary treatment involves exercising theinvolves exercising the muscles.muscles. Positive results arePositive results are more easily attainedmore easily attained with dentate patient.with dentate patient. ImprovementImprovement regardless of theregardless of the exercise program is notexercise program is not permanent and maypermanent and may regress over a period ofregress over a period of even a few hours.even a few hours. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 75. Use of Tongue bladesUse of Tongue blades The simplest and theThe simplest and the least expensiveleast expensive methodmethod A number of tongueA number of tongue blades are placed onblades are placed on the occlusal surfacethe occlusal surface of posterior teeth.of posterior teeth. The patient isThe patient is instructed to pauseinstructed to pause for a few minutesfor a few minutes before placing eachbefore placing each additional blade.additional blade. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 76. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 77. As trismus becomes chronic, there is anAs trismus becomes chronic, there is an appreciable amount of discomfort involved inappreciable amount of discomfort involved in performing the exercises, regardless of theperforming the exercises, regardless of the method used, resulting in patientmethod used, resulting in patient noncompliance.noncompliance. Chronic trismus gradually becomes fibrosis ofChronic trismus gradually becomes fibrosis of the elevator muscles and at this late stage is notthe elevator muscles and at this late stage is not amenable to stretching as a solution.amenable to stretching as a solution. Exercise must begin early in treatment, andExercise must begin early in treatment, and results are predicated on the patient'sresults are predicated on the patient's willingness to cope with the exercise regimen.willingness to cope with the exercise regimen. TrismusTrismus www.indiandentalacademy.comwww.indiandentalacademy.com 78. Shielding and PositioningShielding and Positioning StentsStents In an effort to minimize morbidity associatedIn an effort to minimize morbidity associated with radiation to the oral cavity, soft tissueswith radiation to the oral cavity, soft tissues not directly involved with tumor can benot directly involved with tumor can be displaced or shielded (Kaanders et al, 1992).displaced or shielded (Kaanders et al, 1992). Frequent use of a tongue blade taped to aFrequent use of a tongue blade taped to a cork, for example, when treating lesions incork, for example, when treating lesions in involving the tongue. This simple device, ininvolving the tongue. This simple device, in effect, lowers the mandible and tongue,effect, lowers the mandible and tongue, preventing radiation to the non affectedpreventing radiation to the non affected parotid gland and maxilla to some degree.parotid gland and maxilla to some degree. www.indiandentalacademy.comwww.indiandentalacademy.com 79. Over time, dental oncologists inOver time, dental oncologists in cooperation with radiation therapists havecooperation with radiation therapists have developed more sophisticated shieldingdeveloped more sophisticated shielding and positioning devices that have provenand positioning devices that have proven to be useful in limiting radiation effects.to be useful in limiting radiation effects. www.indiandentalacademy.comwww.indiandentalacademy.com 80. Positioning StentsPositioning Stents One of the most frequently used positioningOne of the most frequently used positioning stents serves to lower the tongue and places it instents serves to lower the tongue and places it in a repeatable position during therapy.a repeatable position during therapy. Since the stent also serves to separate theSince the stent also serves to separate the mandible and maxilla in an open position,mandible and maxilla in an open position, maxillary structures such as the palate, uppermaxillary structures such as the palate, upper gingiva, and buccal mucosa are spared radiationgingiva, and buccal mucosa are spared radiation effects.effects. www.indiandentalacademy.comwww.indiandentalacademy.com 81. Maxillary and mandibular impressions areMaxillary and mandibular impressions are made with irreversible hydrocolloid.made with irreversible hydrocolloid. In the case of the completely edentulousIn the case of the completely edentulous patient, the impressions must be properlypatient, the impressions must be properly extended to ensure stability of the finalizedextended to ensure stability of the finalized bases.bases. Positioning stentsPositioning stents www.indiandentalacademy.comwww.indiandentalacademy.com 82. An interocclusal record is obtained at theAn interocclusal record is obtained at the widest opening necessary to ensure thatwidest opening necessary to ensure that maxillary structures are not included in themaxillary structures are not included in the treatment field.treatment field. Casts are recovered and mounted on aCasts are recovered and mounted on a simple articulator.simple articulator. Positioning stentsPositioning stents www.indiandentalacademy.comwww.indiandentalacademy.com 83. Baseplate wax is softened and placed over the incisal and occlusal surfaces of all the teeth. Two pillars that join the maxillary and mandibular segments and maintain the open interocclusal relationship are fabricated in wax. Positioning stentsPositioning stents www.indiandentalacademy.comwww.indiandentalacademy.com 84. Two sheets of baseplate wax are then attached to the right and left sides of the mandibular segment. This flat sheet extends posteriorly as far as tolerable, covering the entire tongue and maintaining it in the appropriate treatment position. Positioning stentsPositioning stents www.indiandentalacademy.comwww.indiandentalacademy.com 85. Positioning stentsPositioning stents An opening in the anterior portion of the stent between the pillars acts as a shell upon which the tip of the tongue rests and serves to help maintain a repeatable tongue position. www.indiandentalacademy.comwww.indiandentalacademy.com 86. www.indiandentalacademy.comwww.indiandentalacademy.com 87. Shielding StentsShielding Stents It is possible when treating tumorsIt is possible when treating tumors of the buccal mucosa, skin, orof the buccal mucosa, skin, or alveolar ridge with electron beamalveolar ridge with electron beam therapy to protect uninvolvedtherapy to protect uninvolved adjacent structures by means of aadjacent structures by means of a shielding stent.shielding stent. www.indiandentalacademy.comwww.indiandentalacademy.com 88. It is known that a 1 cm thickness of aIt is known that a 1 cm thickness of a Lipowitz alloy (Cerrobend, CerrometalLipowitz alloy (Cerrobend, Cerrometal Products, Bellefort, PA) consisting ofProducts, Bellefort, PA) consisting of silver, copper, tin, antimony, and lead willsilver, copper, tin, antimony, and lead will effectively reduce an 18 MeV electroneffectively reduce an 18 MeV electron beam by approximately 95%.beam by approximately 95%. The metal is only effective, however, whenThe metal is only effective, however, when electrons are used.electrons are used. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 89. Generally, an acrylic resin stent is made.Generally, an acrylic resin stent is made. A portion of the stent is removed and theA portion of the stent is removed and the metal is heated, poured into the preparedmetal is heated, poured into the prepared recess, and allowed to cool.recess, and allowed to cool. The metal is then covered with a layer ofThe metal is then covered with a layer of acrylic resin to prevent back scatter toacrylic resin to prevent back scatter to adjacent tissue.adjacent tissue. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 90. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 91. Maxillary and mandibular impressions are madeMaxillary and mandibular impressions are made using a combination of modeling plastic andusing a combination of modeling plastic and irreversible hydrocolloid in an effort to displaceirreversible hydrocolloid in an effort to displace the tongue laterally.the tongue laterally. An interocclusal wax record is made in centricAn interocclusal wax record is made in centric relation at a slightly opened vertical dimension.relation at a slightly opened vertical dimension. The impressions are poured and the recoveredThe impressions are poured and the recovered casts are mounted on a simple articulator in thecasts are mounted on a simple articulator in the open position.open position. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 92. Baseplate-wax is placed over the mandibularBaseplate-wax is placed over the mandibular teeth on the side to be treated, and theteeth on the side to be treated, and the articulator is closed to form an index of botharticulator is closed to form an index of both maxillary and mandibular teeth.maxillary and mandibular teeth. A wax bolus is formed and attached to theA wax bolus is formed and attached to the occlusal index. The bolus should extendocclusal index. The bolus should extend approximately 1 to 2 cm lingually and contactapproximately 1 to 2 cm lingually and contact both the palate and the floor of the mouth.both the palate and the floor of the mouth. The lingual surface of the stent is made as flatThe lingual surface of the stent is made as flat as possible.as possible. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 93. The waxed stent should be tried in the mouth toThe waxed stent should be tried in the mouth to confirm appropriate extension posteriorly andconfirm appropriate extension posteriorly and sufficient displacement of the tongue.sufficient displacement of the tongue. Once the shape has been confirmed, the waxedOnce the shape has been confirmed, the waxed stent is flasked and processed in clear, heat-stent is flasked and processed in clear, heat- cured or autopolymerizing acrylic resin.cured or autopolymerizing acrylic resin. The stent is recovered and polished as carefullyThe stent is recovered and polished as carefully as possible, making certain that no sharp edgesas possible, making certain that no sharp edges or rough surfaces exist.or rough surfaces exist. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 94. A recess, extending within 8 to 10 mm of theA recess, extending within 8 to 10 mm of the entire circumference of the stent, is cut into theentire circumference of the stent, is cut into the resin to an appropriate uniform depth dependentresin to an appropriate uniform depth dependent on the megavoltage of the electrons to be used.on the megavoltage of the electrons to be used. The Cerrobend is heated and the molten metalThe Cerrobend is heated and the molten metal poured in the hollowed portion of the stent. Thepoured in the hollowed portion of the stent. The metal melts at 158F, at which temperature themetal melts at 158F, at which temperature the acrylic resin will not be damaged.acrylic resin will not be damaged. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 95. After cooling, the patient's name can be cut intoAfter cooling, the patient's name can be cut into the metal surface with a round bur forthe metal surface with a round bur for identification purposes.identification purposes. The exposed metal is covered with additionalThe exposed metal is covered with additional acrylic resin to prevent the metal from contactingacrylic resin to prevent the metal from contacting mucosal surfaces and to minimize backscatter.mucosal surfaces and to minimize backscatter. The completed stent is tried in the mouth inThe completed stent is tried in the mouth in consultation with the radiation therapist.consultation with the radiation therapist. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 96. Shielding stentsShielding stents www.indiandentalacademy.comwww.indiandentalacademy.com 97. Dental Management FollowingDental Management Following RadiationRadiation Mucositis and Loss of TasteMucositis and Loss of Taste Xerostomia and dental cariesXerostomia and dental caries CandidiasisCandidiasis Trismus and FibrosisTrismus and Fibrosis Dental ExtractionsDental Extractions OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 98. www.indiandentalacademy.comwww.indiandentalacademy.com 99. CandidiasisCandidiasis Xerostomic conditions and the change inXerostomic conditions and the change in normal oral flora are thought to be thenormal oral flora are thought to be the causes of increased propensity for thiscauses of increased propensity for this infectioninfection One of the early symptoms is anOne of the early symptoms is an abnormally sore or burning mouth.abnormally sore or burning mouth. www.indiandentalacademy.comwww.indiandentalacademy.com 100. Clinical examination mayClinical examination may reveal some generalizedreveal some generalized inflammation involving theinflammation involving the palate and cheeks, butpalate and cheeks, but lacking the whitishlacking the whitish patches generallypatches generally associated with Candida.associated with Candida. Since irradiated tissueSince irradiated tissue may chronically exhibitmay chronically exhibit some erythema, bacterialsome erythema, bacterial and fungal culturesand fungal cultures should be taken toshould be taken to confirm the presence ofconfirm the presence of Candida.Candida. CandidiasisCandidiasis www.indiandentalacademy.comwww.indiandentalacademy.com 101. If cultures are positive for the fungus,If cultures are positive for the fungus, troches or rinses containing chlotrimazole ortroches or rinses containing chlotrimazole or nystatin are prescribed.nystatin are prescribed. It has been suggested that meticulous oralIt has been suggested that meticulous oral hygiene and frequent rinsing with salt andhygiene and frequent rinsing with salt and soda or dilute solutions of hydrogen peroxidesoda or dilute solutions of hydrogen peroxide may have a preventive effect.may have a preventive effect. Some clinicians have reported daily rinsesSome clinicians have reported daily rinses with chlorhexidine to be beneficial.with chlorhexidine to be beneficial. CandidiasisCandidiasis www.indiandentalacademy.comwww.indiandentalacademy.com 102. Clinical experience has demonstrated thatClinical experience has demonstrated that Candida may be harbored in or on theCandida may be harbored in or on the surface of dentures or obturators and playsurface of dentures or obturators and play a role in chronic reinfection.a role in chronic reinfection. Soaking prostheses in an antifungalSoaking prostheses in an antifungal solution of dilute hypochlorite for completesolution of dilute hypochlorite for complete dentures has proven to be an effectivedentures has proven to be an effective preventative measure.preventative measure. CandidiasisCandidiasis www.indiandentalacademy.comwww.indiandentalacademy.com 103. Dental ExtractionsDental Extractions Patients receiving cancericidal doses ofPatients receiving cancericidal doses of radiation to the mandible or maxilla experienceradiation to the mandible or maxilla experience diminished ability to heal when even mild traumadiminished ability to heal when even mild trauma causes loss of mucosal integrity and subsequentcauses loss of mucosal integrity and subsequent exposure of devitalized bone. This condition,exposure of devitalized bone. This condition, defined as osteoradionecrosis (ORN).defined as osteoradionecrosis (ORN). Any oral surgery procedures performed followingAny oral surgery procedures performed following radiation may result in delayed wound healingradiation may result in delayed wound healing accompanied by considerable pain andaccompanied by considerable pain and discomfort.discomfort. www.indiandentalacademy.comwww.indiandentalacademy.com 104. Well-planned surgical studies usingWell-planned surgical studies using antibiotics and precise techniques reportantibiotics and precise techniques report incidences of ORN from as little as 1% toincidences of ORN from as little as 1% to as high as 30%.as high as 30%. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 105. It has been suggested that extremelyIt has been suggested that extremely mobile, periodontally compromised teethmobile, periodontally compromised teeth can be safely minimal risk of developingcan be safely minimal risk of developing ORN.ORN. Localized periapical or periodontalLocalized periapical or periodontal infection can be managed conservativelyinfection can be managed conservatively with antibiotics, avoiding the immediatewith antibiotics, avoiding the immediate need for tooth removal.need for tooth removal. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 106. In situations involving single teeth, endodonticsIn situations involving single teeth, endodontics should be considered an option even when theshould be considered an option even when the tooth is considered non restorable. Followingtooth is considered non restorable. Following endodontic therapy, the badly decayed toothendodontic therapy, the badly decayed tooth crown is amputated to prevent irritation to thecrown is amputated to prevent irritation to the tongue or cheek and the exposed portion of thetongue or cheek and the exposed portion of the root canal is scaled with a permanentroot canal is scaled with a permanent restoration. A tooth managed in this mannerrestoration. A tooth managed in this manner may serve no function but, more important,may serve no function but, more important, extraction is avoided.extraction is avoided. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 107. Teeth located in areas not included in theTeeth located in areas not included in the radiation fields can be extracted safely.radiation fields can be extracted safely. All too frequently, patients present whoAll too frequently, patients present who have need of multiple extractions.With thehave need of multiple extractions.With the use of hyperbaric oxygen, extensive oraluse of hyperbaric oxygen, extensive oral surgery can be performed with asurgery can be performed with a substantially diminished risk of necrosissubstantially diminished risk of necrosis (Marx, 1983).(Marx, 1983). Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 108. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 109. Hyperbaric protocols involve a series of upHyperbaric protocols involve a series of up to 20 "dives" before and after surgery in ato 20 "dives" before and after surgery in a small, sealed hyperbaric chamber. Eachsmall, sealed hyperbaric chamber. Each daily dive is 90 minutes long.daily dive is 90 minutes long. Teeth are extracted following the initial 20Teeth are extracted following the initial 20 dives.dives. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 110. Extractions are generally performed in theExtractions are generally performed in the operating room.operating room. Necessary surgery including extractions,Necessary surgery including extractions, alveolectomies, and tori removal arealveolectomies, and tori removal are completed using atraumatic technique.completed using atraumatic technique. The wounds are closed primarily.The wounds are closed primarily. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 111. Following the surgical procedures, theFollowing the surgical procedures, the patient returns for the completion of thepatient returns for the completion of the second phase of the hyperbaricsecond phase of the hyperbaric protocol.protocol. Additional dives may be necessary ifAdditional dives may be necessary if wound healing is not complete.wound healing is not complete. Dental ExtractionsDental Extractions www.indiandentalacademy.comwww.indiandentalacademy.com 112. www.indiandentalacademy.comwww.indiandentalacademy.com 113. OsteoradionecrosisOsteoradionecrosis It has been proposed in the past that ORNIt has been proposed in the past that ORN may result from trauma, exposure ofmay result from trauma, exposure of radiated bone, and infection.radiated bone, and infection. Others have more recently advocated thatOthers have more recently advocated that the cause may be related to thethe cause may be related to the hypovascular, hypocellular, and hypoxichypovascular, hypocellular, and hypoxic conditions that exist in bone followingconditions that exist in bone following radiation.radiation. www.indiandentalacademy.comwww.indiandentalacademy.com 114. Although trauma is thought by some to beAlthough trauma is thought by some to be a necessary initiating factor, numerousa necessary initiating factor, numerous spontaneous cases of ORN have beenspontaneous cases of ORN have been reported.reported. The type of radiation treatment employed,The type of radiation treatment employed, dosage, and tissue volume involved aredosage, and tissue volume involved are also considered contributing factors.also considered contributing factors. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 115. Clinical observation indicates ORN isClinical observation indicates ORN is more prevalent in the mandible thanmore prevalent in the mandible than maxilla.maxilla. Improved radiation techniques and betterImproved radiation techniques and better cooperation between dentist and radiationcooperation between dentist and radiation oncologist have reduced the incidences ofoncologist have reduced the incidences of ORN from highs in the 1960s of 32% toORN from highs in the 1960s of 32% to about 9% today.about 9% today. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 116. Clinical examination will generally reveal aClinical examination will generally reveal a soft tissue ulcer and an area of exposedsoft tissue ulcer and an area of exposed bone.bone. Any such wound should be viewed withAny such wound should be viewed with suspicion, and the possibility of recurrentsuspicion, and the possibility of recurrent tumor must be ruled out.tumor must be ruled out. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 117. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 118. Initial treatment should be conservative.Initial treatment should be conservative. The lesion is carefully cleansed and anyThe lesion is carefully cleansed and any small sequestered bony fragments aresmall sequestered bony fragments are carefully removed.carefully removed. Oral hygiene procedures are reviewed andOral hygiene procedures are reviewed and the patient is asked to rinse frequently withthe patient is asked to rinse frequently with dilute hydrogen peroxide or a salt anddilute hydrogen peroxide or a salt and soda solution in an effort to keep the areasoda solution in an effort to keep the area moist and clean.moist and clean. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 119. Dentures, if present, are relieved over theDentures, if present, are relieved over the affected area, and the patient may beaffected area, and the patient may be cautioned to use the dentures only whilecautioned to use the dentures only while eating.eating. Conversely, it is thought by some that theConversely, it is thought by some that the denture serves to protect the wound anddenture serves to protect the wound and prevent further irritation from movementsprevent further irritation from movements of the tongue.of the tongue. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 120. Following initial treatment, the patient isFollowing initial treatment, the patient is seen at frequent intervals to evaluate theseen at frequent intervals to evaluate the wound and reinforce home carewound and reinforce home care procedures.procedures. When sequestra are evident, they may beWhen sequestra are evident, they may be judiciously removed and the area keptjudiciously removed and the area kept smooth to avoid irritation to surroundingsmooth to avoid irritation to surrounding tissues.tissues. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 121. Unfortunately, healing does not alwaysUnfortunately, healing does not always occur with conservative treatment.occur with conservative treatment. The non responsive affected area willThe non responsive affected area will enlarge with time, be subject to moreenlarge with time, be subject to more frequent severe infection, and causefrequent severe infection, and cause considerable pain.considerable pain. Pathologic fracture of the mandible mayPathologic fracture of the mandible may also be a finding.also be a finding. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 122. In these situations the patient is referred forIn these situations the patient is referred for hyperbaric oxygen therapy.hyperbaric oxygen therapy. After the initial series of dives, surgery, in mostAfter the initial series of dives, surgery, in most instances, is performed followed by a secondinstances, is performed followed by a second series of dives.series of dives. Substantial portions of the mandible may beSubstantial portions of the mandible may be removed leading to discontinuity defects.removed leading to discontinuity defects. Mandibular reconstruction using microvascularMandibular reconstruction using microvascular surgical techniques may be necessary to restoresurgical techniques may be necessary to restore patient function.patient function. OsteoradionecrosisOsteoradionecrosis www.indiandentalacademy.comwww.indiandentalacademy.com 123. Prosthodontic ManagementProsthodontic Management Patients treated with radiation sufferPatients treated with radiation suffer substantial changes to the oral mucosasubstantial changes to the oral mucosa and are often candidates for newand are often candidates for new complete or partial dentures.complete or partial dentures. The oral soft tissue must be adequatelyThe oral soft tissue must be adequately healed before necessary prosthodontichealed before necessary prosthodontic procedures can be initiated.procedures can be initiated. www.indiandentalacademy.comwww.indiandentalacademy.com 124. Since trauma caused by denturesSince trauma caused by dentures may increase the potential risk ofmay increase the potential risk of mucosal irritation and subsequentmucosal irritation and subsequent bone exposure, some havebone exposure, some have suggested waiting at least 6 monthssuggested waiting at least 6 months to a year before dentures areto a year before dentures are contemplated.contemplated. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 125. Clinical experience has demonstrated thatClinical experience has demonstrated that dentures can be made for somedentures can be made for some individuals in a matter of 2 or 3 monthsindividuals in a matter of 2 or 3 months following radiation with little complication.following radiation with little complication. Conversely, some patients will never wearConversely, some patients will never wear dentures successfully because of radiationdentures successfully because of radiation effects.effects. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 126. Dentures should be carefully fabricatedDentures should be carefully fabricated using conventional prosthodonticsusing conventional prosthodontics techniques.techniques. The dentist may be well served by using aThe dentist may be well served by using a familiar technique, thereby avoiding thefamiliar technique, thereby avoiding the need for multiple remakes and anneed for multiple remakes and an unpredictable result.unpredictable result. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 127. It has been reported that plaster or zincIt has been reported that plaster or zinc oxide may cause some discomfort relatedoxide may cause some discomfort related to tissue friability and the lack of saliva.to tissue friability and the lack of saliva. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 128. Denture border extensions are developedDenture border extensions are developed with modeling plastic.with modeling plastic. This material must be properly temperedThis material must be properly tempered prior to placement in the mouth to preventprior to placement in the mouth to prevent soft tissue irritation.soft tissue irritation. Soft tissues are manipulated as gently asSoft tissues are manipulated as gently as possible during the impression process.possible during the impression process. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 129. A closed vertical dimension is believed to placeA closed vertical dimension is believed to place less stress on the alveolar ridges during functionless stress on the alveolar ridges during function and parafunction and may also be an advantageand parafunction and may also be an advantage in positioning the denture should trismus orin positioning the denture should trismus or fibrosis develop.fibrosis develop. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 130. The plastic, monoplane tooth is frequentlyThe plastic, monoplane tooth is frequently the tooth of choice.the tooth of choice. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 131. A well-balanced, non interferingA well-balanced, non interfering occlusion is an absolute necessityocclusion is an absolute necessity regardless of the tooth form used.regardless of the tooth form used. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 132. Soft materials have been suggested forSoft materials have been suggested for use as denture bases.use as denture bases. These materials have offered littleThese materials have offered little advantage over hard base materialsadvantage over hard base materials because of their coarse surface andbecause of their coarse surface and propensity for support of fungal growth.propensity for support of fungal growth. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 133. Delivery procedures must be meticulouslyDelivery procedures must be meticulously performed.performed. Indicating paste is used to identify theIndicating paste is used to identify the areas of excessive pressure.areas of excessive pressure. Denture borders should be carefullyDenture borders should be carefully evaluated for areas of overextension,evaluated for areas of overextension, paying special attention to thepaying special attention to the retromylohyoid area.retromylohyoid area. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 134. The dentures should be highly polished.The dentures should be highly polished. Some clinicians advocate that the tissue-bearingSome clinicians advocate that the tissue-bearing surface of the denture also be polished tosurface of the denture also be polished to eliminate any surface roughness in an effort toeliminate any surface roughness in an effort to minimize tissue irritationminimize tissue irritation Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 135. The patient should be advised regardingThe patient should be advised regarding the effect xerostomia and compromisedthe effect xerostomia and compromised mucosa have on the potential formucosa have on the potential for prosthodontic success and should beprosthodontic success and should be cautioned to remove the dentures if anycautioned to remove the dentures if any soreness or irritation develop and to seesoreness or irritation develop and to see the dentist as quickly as possible.the dentist as quickly as possible. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 136. The benefits of removing the dentures whileThe benefits of removing the dentures while asleep and maintaining appropriate oral hygieneasleep and maintaining appropriate oral hygiene procedures must be explained.procedures must be explained. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 137. Additionally, the patient must be seen atAdditionally, the patient must be seen at frequent intervals during the first fewfrequent intervals during the first few weeks allowing delivery of the dentures.weeks allowing delivery of the dentures. Two appointments a week provide ampleTwo appointments a week provide ample opportunity to intercept any problems thatopportunity to intercept any problems that may develop.may develop. Prosthodontic management www.indiandentalacademy.comwww.indiandentalacademy.com 138. Implants in the irradiated boneImplants in the irradiated bone The long term function of osseointegratedThe long term function of osseointegrated implants is dependent on the presence ofimplants is dependent on the presence of viable bone that is capable of remodelingviable bone that is capable of remodeling as the implant is subjected to the stressesas the implant is subjected to the stresses associated with the support of a prostheticassociated with the support of a prosthetic restoration.restoration. www.indiandentalacademy.comwww.indiandentalacademy.com 139. When implants are considered for theWhen implants are considered for the irradiated patient, several issues requireirradiated patient, several issues require careful assessment:careful assessment: Risk of osteoradionecrosis.Risk of osteoradionecrosis. Potential benefit provided by implantsPotential benefit provided by implants Potential morbidity associated with implantPotential morbidity associated with implant failurefailure Possible use of HBO as an adjunct treatment.Possible use of HBO as an adjunct treatment. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 140. The predictability of endosseous implantsThe predictability of endosseous implants in irradiated bone depends upon:in irradiated bone depends upon: Selected anatomic siteSelected anatomic site Dosage to the siteDosage to the site Use of HBOUse of HBO Timing of implant placement in relation to theTiming of implant placement in relation to the radiation treatment.radiation treatment. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 141. A study by Larsen et al demonstrated thatA study by Larsen et al demonstrated that the mean integration of implants placed inthe mean integration of implants placed in a non-irradiated group of dogs wasa non-irradiated group of dogs was significantly greater than in an irradiatedsignificantly greater than in an irradiated group.group. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 142. Asikainen et al showed that in an experimentalAsikainen et al showed that in an experimental dog model, implant survival was dose related.dog model, implant survival was dose related. The animals received 4000, 5000, or 6000 cGy,The animals received 4000, 5000, or 6000 cGy, and implants were placed 2 months later. After 4and implants were placed 2 months later. After 4 months of osseointegration, the implants weremonths of osseointegration, the implants were loaded for 6 months.loaded for 6 months. The success rates were 100% in the 4,000 cGyThe success rates were 100% in the 4,000 cGy group, 20% in the 5,000 cGy group, and 0% ingroup, 20% in the 5,000 cGy group, and 0% in the 6,000-cGy group.the 6,000-cGy group. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 143. Parel and Tjellstroerrv in a survey ofParel and Tjellstroerrv in a survey of centers in the United States and Sweden,centers in the United States and Sweden, reported 64.7% and 57% success rates,reported 64.7% and 57% success rates, respectively, for extraoral implants placedrespectively, for extraoral implants placed in irradiated facial bones.in irradiated facial bones. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 144. Roumanas et alRoumanas et al reported resultsreported results accumulated over 14 years for craniofacialaccumulated over 14 years for craniofacial implants placed in the facial skeleton toimplants placed in the facial skeleton to retain facial prostheses.retain facial prostheses. The success rate of implants placed inThe success rate of implants placed in irradiated bone was 52%, versus 85% forirradiated bone was 52%, versus 85% for those placed in nonirradiated bone.those placed in nonirradiated bone. Long-term success rates in the irradiatedLong-term success rates in the irradiated orbit were particularly low (27%).orbit were particularly low (27%). Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 145. Marxs ProtocolMarxs Protocol 20 dives before and 10 after implant placement20 dives before and 10 after implant placement at 2.4 atmospheric pressure for 90 minutes.at 2.4 atmospheric pressure for 90 minutes. Niimi et al conducted a nationwide survey inNiimi et al conducted a nationwide survey in Japan on oral implants placed followingJapan on oral implants placed following radiation. The success rate for implants placedradiation. The success rate for implants placed in the maxilla without HBO was 62.5%; thein the maxilla without HBO was 62.5%; the success rate for maxillary implants that receivedsuccess rate for maxillary implants that received HBO treatment was 80%.HBO treatment was 80%. Implants in the irradiated boneImplants in the irradiated bone www.indiandentalacademy.comwww.indiandentalacademy.com 146. Irradiation of Implants in BoneIrradiation of Implants in Bone Irradiation of titanium implants already inIrradiation of titanium implants already in place results in backscatter; therefore, theplace results in backscatter; therefore, the tissues on the ra-diation source side of thetissues on the ra-diation source side of the implants receive a higher dose than theimplants receive a higher dose than the other tissues in the field.other tissues in the field. The dose is increased by about 15% at 1The dose is increased by about 15% at 1 mm from the implant.mm from the implant. www.indiandentalacademy.comwww.indiandentalacademy.com 147. ConclusionConclusion Dental management of the irradiated patient is aDental management of the irradiated patient is a serious undertaking since the standard of careserious undertaking since the standard of care certainly has an effect on the patient's quality ofcertainly has an effect on the patient's quality of life. Dentists assuming the responsibility forlife. Dentists assuming the responsibility for treating this group must be willing to make a long,treating this group must be willing to make a long, term commitment to each individual patient's care.term commitment to each individual patient's care. www.indiandentalacademy.comwww.indiandentalacademy.com 148. They must also have an understanding ofThey must also have an understanding of basic radiation and dental oncologybasic radiation and dental oncology techniques and their own limitations.techniques and their own limitations. www.indiandentalacademy.comwww.indiandentalacademy.com 149. REFERENCES Clinical Maxillofacial Prosthetics Thomas D. Taylor Maxillofacial Prosthetics - WR Laney. Maxillofacial Prosthetics : Multidisciplinary Practice Chalian, Drane & Standish. Radiation therapy for oral cavity cancer. DCNA 1990;34(2):205-222. Oral tissue changes of radiation oncology and their management. DCNA 1990;34(2):223-238. 150. Fleming TJ, Rambach SC. A tongue shielding radiation stent. J Prosthet Dent 1983;48:389-392. Marx RE. A new concept in treatment of osteoradionecrosis. J oral maxillofac Surg 1983;41:351-356. Marx RE. Osteoradionecrosis: A new concept in its pathophysiology. J oral Maxillofac Surg 1986;41:283-287. Oral management of a radiotherapy patient. DCNA 2004. 151. Oral Tissue and radiation. JPD 1963;72-84. Implants in qualitatively compromised bone. Watzenick 2nd ed. 152. Thank You For more details please visit www.indiandentalacademy.com 153. Any Doubts ???