1 Volume 22 2023 e238447 Original Article Braz J Oral Sci. 2023;22:e238447http://dx.doi.org/10.20396/bjos.v22i00.8668447 1 MSc student, School of Dentistry, Federal University of Uberlândia (UFU), Uberlândia, MG, Brazil. 2 Undergraduate student, School of Dentistry, Federal University of Uberlândia (UFU), Uberlândia, MG, Brazil. 3 PhD student, School of Dentistry, Federal University of Uberlândia (UFU), MG, Brazil. 4 Professor at Dentistry Department, School of Dentistry, CEUMA University (UNICEUMA), São Luís, Maranhão, Brazil. 5 PhD student, School of Dentistry, CEUMA University (UNICEUMA), São Luís, MA, Brazil. 6 Professor of Periodontology and Implantology Department, School of Dentistry, Federal University of Uberlândia (UFU), MG, Brazil. Corresponding author: Priscilla Barbosa Ferreira Soares, DDS, Mas, PhD, CEUMA University, School of Dentistry. Av. Pará, 1720, Bloco 4L, Anexo A, Campos Umuarama CEP: 38400-902, Uberlândia, Minas Gerais, Brazil. pbfsoares@yahoo.com.br Editor: Altair A. Del Bel Cury Received: Feb 17, 2022 Accepted: Jun 6, 2023 Clinical dental management of the head and neck irradiated patient: topics of interest for clinicians Nuryê Rezende Prisinoto1 , Cariniana Macedo de Alcântara2 , Dhiancarlo Rocha Macedo3 , Meire Coelho Ferreira4 , Daniela Malagoni Fagundes5 , Priscilla Barbosa Ferreira Soares6* Aim: To discuss important topics regarding the dental procedures performed in patients before, during and after the radiotherapy treatment. The biological effects of ionizing radiation on bone tissue focusing on clinical care will be described. The invasive and not invasive procedures after radiotherapy treatment in the head and neck region will be addressed using scientific evidences to determine the appropriate moment for tooth extractions, periodontal management, and preventive procedures for osteoradionecrosis. Methods: Thirty-three studies including original studies and reviews were selected in MEDLINE database (PubMed). No year of publication restriction was applied. Language was restricted to the English, and the following Medical Subject Heading terms were used: radiotherapy, osteoradionecrosis, dental management. Studies of osteoradionecrosis involving clinical management of irradiated patients, with an emphasis on updated guidelines and protocols were selected. Results: Care in dental procedures were related about restorative treatment, endodontic treatment, rehabilitation for edentulous regions using prostheses and implants and periodontal procedures before, during and after RTX treatment. Conclusions: The dental procedures should and can be performed before, during but also after radiotherapy. However, the clinical procedures should be less invasive as possible. A maintenance plan that reduces the necessity for major and more invasive treatments after radiotherapy is recommended. Keywords: Head and neck neoplasms. Radiotherapy. Osteoradionecrosis. https://orcid.org/0000-0001-6254-8854 https://orcid.org/0000-0002-8033-6086 https://orcid.org/0000-0002-9241-5187 https://orcid.org/0000-0001-7116-1547 https://orcid.org/0000-0002-4439-262X https://orcid.org/0000-0002-4492-8957 2 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 Introduction Radiotherapy (RTX) treatment is widely used to treat various types of head and neck cancers1. The purpose of RTX is to control the growth or elimination of the tumor1, reducing the possibility of recurrence and improving the patient’s quality of life1. RTX treatment is indicated as a palliative protocol of incurable cancers1. Despite of the benefits of this therapy, some patients frequently are involved with adverse effects caused by ionizing radiation2,3. The main complications associated with RTX are: mucositis, xerostomia, changes in salivary quality and quantity, opportunistic infec- tions, tissue fibrosis, sensory dysfunctions such as dysgeusia, increased periodontal disease progression, caries and osteoradionecrosis (ORN)4. These intercurrences can have acute manifestation, during the treatment, or chronic manifestation after the completion of the treatment4. The clinical characteristic of ORN is bone necrosis due to hypoxia, hypovascular- ization and hypocellularity5, with loss of mucosal integrity, associated or not with oral environment bone exposure2. The ORN is the most serious adverse effect of RTX, compromising the tissue integrity and health of the oral structures. The ORN incidence ranges from 5 to 30% of patients who have undergone head and neck RTX3. The incidence of RTX has decreased with the use of the most modern radiation techniques3. Several risk factors are associated with the development of the ORN, such as smoking, periodontal disease, alcohol abuse, intensity and duration of radiation2. Controlling the risk factors is important to minimize the development of ORN. The approaches pro- posed for the treatment of ORN involve non-invasive techniques such as maintaining the quality of oral hygiene, the use of antibiotic therapy, and also extensive surgical procedures to remove the necrotic bone2. The high uncertainty rate of the infection control is a factor that must be considered for choosing the ideal treatment2. The knowledge about the manifestations caused by ionizing radiation in the oral cav- ity has great importance for clinicians. Many professionals still have doubts regarding the treatment planning and the management of patients involved with RTX. Despite some other reviews have been focused on the management of the head and neck cancer patients6,7, the continuous update of the information about the specific care about the preventive and therapeutic procedures in patients’ wit history of head and neck cancer is of a paramount importance. Therefore, this study aimed to describe and clarify the dental procedures performed by clinicians in cancer patients before, during and after RTX treatment. Materials and methods Thirty-three studies were included in this narrative review. twenty-one these stud- ies were original researches while twelve were reviews. The reviews of literature were no excluded due to the informative nature of this review, approaching differ- ent protocols of care in the head and neck irradiated patient. These studies were searched in the MEDLINE databases (PubMed). All selected through the focus on the management of irradiated patients in the head and neck region. No pub- 3 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 lication year restriction was applied. The language was restricted to English, and the following Medical Subject Heading terms were used: radiotherapy, osteora- dionecrosis, dental management. Studies on osteoradionecrosis involving clinical management of irradiated patients, with an emphasis on updated guidelines and protocols, were selected. Dental procedures before and during RTX treatment Before starting RXT, the professional must perform all necessary adequacy of the oral environment1. Caries lesions treatment, subgingival scaling, endodontic treat- ments or tooth extraction that could be the focus of infection should be performed2. These procedures should be performed at least two weeks before to start the RTX treatment2. The prevention of ORN is based on elimination of the oral cavity infec- tious conditions at the pre-RXT phase, as well as to prevent the invasive procedures during and after RXT treatment8. Monitoring the quality of oral hygiene should be also always performed, since the development of ORN is also associated with poor oral hygiene8. During the irradiation period, mucositis, opportunistic infections such as candidiasis, salivary gland dysfunctions such as xerostomia and taste alterations are frequently reported by patients9. During the RTX, invasive dental procedures are not recom- mended2. Prior monitoring the patient oral conditions should be performed2, except in cases the occurrence of an emergency, then the invasive procedures are necessary for maintaining the patient’s safety and health. Dental procedures after RTX treatment Post- RXT patients may have chronic complications such as ORN, xerostomia and trismus9. The irradiated patients may need dental care requiring the performance of various dental procedures, such as tooth restorations, endodontics, rehabilitation, among others10,11. It is important that clinicians understand the consequences of RTX on the mucosa, bone tissue and dental tissue to prevent the installation of ORN and failure of clinical procedures12. Ionizing radiation produces hypoxia, hypocellularity and hypovascularization that can alter the regenerative potential of the soft and hard tissues2,13,14. Changes in tooth and bone structure can occur due to degradations in amine components that can mechanically alter enamel15,16, dentin12, and bones14,15,17. The effect of ionizating radia- ton on the salivary flow and the xerostomia reduce the protection of this fluid against pathogens and enhance the friction on the mucosa during the oral chewing that could be the trigger for the occurrence of the mucositis lesions18. Extractions Post-RTX extraction is an important risk factors for the development of the ORN19, then this procedure should be avoided during this period3. A safety period for the development of the ORN is inconclusive3,12. The tooth extractions performed during post-RTX can result on ORN, due the invasive procedure in bone and mucosa tissues, which can compromise the microarchitecture and vascularization3,5,12,19. 4 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 A retrospective study evaluated 32 patients with tooth extraction after RTX and showed the ORN in 12.1% (9 patients)19. The patients with ORN received higher radiation dose (62.0 Gy vs. 37.4 Gy) and longer treatment time until extraction (41.2 months vs. 28.2 months) than the groups of patients without ORN. The recent systematic demonstrates that the presence of risk factors such as smoking, radia- tion dose and duration of treatment are more predictable aspects in decision-making when performing dental extractions than the time after RTX3. The possibility of occurrence of ORN after tooth extraction is a possible and uncer- tain complication. If necessary, the extraction should be performed less traumati- cally possible, avoiding large flaps and osteotomies in order to improve the healing process2. Adjunct therapies, such as photobiomodulation, ozonetherapy, PENTOCLO protocol, hyperbaric chambers, may also be indicated, as early intervention may reduce the risk of ORN20. Restorative treatment In irradiated patients increased the risk of developing dental carious lesions due to multiple factors21,22. The development of carious lesions after RTX treatment can occur mainly from three months after irradiation and can lead to a severe oral health impact15,22,23. These effects can occur due to the degradation of the organic components of dentin and enamel, which stimulate the increasing of its rigidity, making less efficient to support occlusal forces, which leads to the tooth wear23,24. The reduction or qualitative alteration of salivary flow turns the patients as a greater risk for developing dental caries due the limited pH buffering function promoted by saliva, as well as the dryness of the oral mucosa that makes oral hygiene proce- dures more uncomfortable18,24. The rapid progression of the carious lesions on enamel and dentin and the structural substrate changes make the restorative protocols a major challenge due the poorly adhesive interaction with the dental substrate12,24,25. It has been indicated the use of the neutral fluor application periodically23,26. In patients with xerostomia and high risk of radiation carious lesions and poor adherence to preventive fluoride therapy, the use of conventional and resin modified glass ionomer cement are more effective in protecting recurrent carious lesions10. Surgical and non-surgical periodontal treatment Periodontal disease occurs due to an imbalance between the periodontal microbiota and the host response, and the process of oral dysbiosis may be responsible in part for the disease progression8. RTX can be an important agent for periodontal micro- biota dysbiosis due to reduced salivary flow, which is associated with less efficient oral hygiene27. RTX induced fibrotic effects on connective tissues make periodontal tissues less competent in regenerative processes due to reduced oxygenation found especially in terminal-type circulation28. These effects together increase the host’s susceptibility to present more aggressive periodontal disease, increasing the risk of tooth loss after RTX treatment29. 5 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 Due to the risks of ORN after tooth extraction, a personalized treatment and mainte- nance plan must be indicated considering the periodontal health status and systemic conditions pre-RXT8. The treatments must be completed as soon as possible before RTX, being the full-mouth scaling technique is indicated27,28. Periodontal therapy for head and neck cancer implemented before, during and after treatments results in a significant improvement on periodontal health, but this therapy should be maintained, otherwise periodontal disease continues its progression8,28. Endodontic treatment Due to the increased carious lesions activity in patients after RTX, endodontic treatment should be necessary to avoids more aggressive procedures such as extraction11,21. However, some factors such as the reduction of the dental pulp oxy- genation the structural tooth fragilization can complicate the diagnosis and reduce the endodontic treatment success11,21. Pulp oxygenation levels are reduced after 4-6 months, which can impair pulp diagnosis by promoting a negative sensitivity response in vital pulps and directing unnecessary endodontic interventions21. If pulp exposure is present, 6-12 months should be performed, due the transitory loss of pulp sensitivity caused by RTX21. The endodontic treatment associated with RTX, can increase the tooth structural weakening21. Resin composite restorations are recommended to direct restorative material for restoring the endodontically treated teeth, strongly avoiding the use of the amalgam30. It is also important and recom- mended to replace amalgam restorations prior to RTX treatment31. Rehabilitation for edentulous regions using prostheses and implants Most irradiated patients mainly seek treatment for edentulous regions, usually as a result of multiple tooth extractions performed before RTX treatment12. Oral rehabil- itation is important to improve the patient’s quality of life31. It is essential that the clinicians understand the procedures that should be avoided in this post-radiation period32. Treatments with partial or complete dentures must be carefully performed. The patient follow-up is essential so mismatched dentures can cause damage to the mucosa can generate trauma that predisposes ORN31,33. It is not well established the safer rehabilitation procedure for post- RTX patients32. When fixed prostheses are indicated, it should be taking in consideration that the tooth substrate after the RTX become more fragile, reducing the predictability of this treatment12. Another alternative for oral rehabilitation is the use of dental implants supported prostheses without interfering with compromised mucous membranes and teeth32,33. The installation of implants prior to RTX is safer pro- cedure with high success and survival levels33. The installation of implants after the RTX period present a slightly higher level of complication compared with the implants installed in the general population32. The innovations on macrostructure and microstructure implants surface, and on the implant installation techniques guided by surgery without flap opening, can make the rehabilitation of post-radio- therapy patients increasingly safer and more predictable, but this clinical proce- dures still requires further investigations. 6 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 Discussion The treatment of head and neck cancer is an extremely challenging condition for maintain the patient’s quality of life. The patients tend to resist to the highly aggres- sive treatments such as extensive surgery to remove the tumor, the RTX protocol, and in many situations to perform multiple tooth extractions prior to the RTX3. During and after the period of active treatment, therapeutic planning aiming proper oral rehabili- tation is necessary in order to limit the acute and chronic damage caused by cancer treatment2. It is important to recognize that the effects of RTX are cumulative, and the indication of the dental procedures must consider the limitations imposed by the alterations on the dental and bone caused by irradiation, avoiding as much as possible the occurrence of ORN. To avoid this complication, has been suggested not performing dental extraction due the ORN19. Bone tissue intervention should ideally be performed before RTX3. This indi- cation is based on the progressive process of connective tissue fibrosis that reduces the vascularization, cellularity and oxygenation of oral tissues, especially bone tis- sue, which can impair the repair processes5,12,13,28. The bone tissue has the slower regenerative potential than soft tissues2,5,14,28. During the healing phase, especially the post-extraction alveolar repair occurred by second intention, makes this tissue more susceptible to contamination and subsequent development of necrotic lesions, which are difficult to treat2. There is an important relationship between the occurrence of cancer in the head and neck region and poor periodontal conditions, since the risk factors are shared27,29. It is expected that patients indicated for RTX treatment may have more severe and active periodontal disease than the general population29. Periodontal treatment after RTX should be performed as quickly and less aggressively as possible, avoiding surgical procedures to access root surfaces8,29. Supportive periodontal therapy should be per- formed at least every 3 months to prevent disease progression that the risk of tooth loss4. It is recommended that teeth with a questionable periodontal prognosis should be removed at least 14 days prior to initiation of RTX28. If the treatment plan and preventive procedures before RTX are indicated for the teeth maintenance. Special attention is essential due the changes in the protein portion on the dentin, enamel and at the cementoenamel junction substrate. Associated with the salivary flow reduction the developing radiation carious lesions is increased15,22. The adhesive systems efficiency is reduced in forming prober hybrid layer to den- tin substrate and the different restorative materials12. Thus, restorative materials that allow the continuous release the fluoride, such as conventional or resin modified glass ionomer cements should be chosen, reducing the recurrent carious lesions, and the dependence on the bonding interface promoted by adhesive systems12. More exten- sive carious lesions with pulp involvement may indicate endodontic therapy, that will further weaken the tooth structure affected by RTX34. The dosage used and the time elapsed of the RTX should be taken in consider- ation during the planning of the rehabilitation of the edentulous areas28. It has been described that muco-supported prostheses must be well adapted to avoid trauma to the mucosa, as this tissue is also fragile and can more easily lose its integrity and 7 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 expose the adjacent bone tissue31. The denture-supported dentures planning must consider the quality of the remaining abutment teeth, avoiding involving teeth with large restorations with endodontic treatment as abutments11,21. Teeth with a history of periodontal disease are more susceptible to disease progression after RTX and should also be avoided as support for protheses4. The security of the implant placement in patients after the RTX are inconclusive. It has been described that the rehabilitation with dental implants has been indicated as a good alternative to rehabilitate patients after RTX and has shown relatively good levels of clinical survival33. It has been also showed that the bone tissue surgery may present higher risk factor for the ORN installation34. Indeed, the myriad of protocols of RTX impairs a properly documentation regarding the safety for implants placement in these patients19. Technological advances may improve the outcomes of the oral treatment in the RTX patients. The advances in the mechanical of the restorative materials associ- ated with adhesive procedures, and preventive protocols may improve the treatment complication related with the carious lesions11,30. The implants design and micro- structure advantages, as well as the use of less traumatic surgeries may enhance the oral rehabilitation predictability35. In addition, the dental therapy may become more safety as much the RTX protocols become more focused on injuries33. The dental treatment after RTX is possible to be performed, but they should be less invasive as possible. Conclusion In conclusion, the dental procedures before, during and after RTX should be performed, however they should be always less invasive as possible. However, the type complex- ity of the treatment is patient and moment dependent. A maintenance plan performed before, during and after RTX is strongly recommended to reduce the necessity for major and more invasive treatments after radiotherapy. Acknowledgements This study was supported by the research funding agencies FAPEMIG, CNPq and CAPES. Conflict of interest None. Authors Contribution All authors actively participated in the discussion of the manuscript findings, reviewed, and approved the final version of this manuscript. Data availability Datasets related to this article will be available upon request to the corresponding author. 8 Prisinoto et al. Braz J Oral Sci. 2023;22:e238447 References 1. Spijkervet FKL, Brennan MT, Peterson DE, Witjes MJH, Vissink A. 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