Dr Mohammed Malik Afroz
Radiation Induced Changes
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Fibrosis of musculature
Masticatory inadequacy (chewing with less force)
Impaired Deglutition (swallowing)
Altered response to irritation, infection
Trismus
Capillary Fragility
Increased Vascular Permeability
Oral Incompetence (lips not closing)
Tissue fragility and friability(crushed)
Decreased repair potential
Fear, Depression.
Golden Period – 6 week period following RT
Adverse Effects
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Susceptibility to soft tissue necrosis
Susceptibility to osteoradionecrosis
Increased susceptibility to radiation caries
Susceptibility to infection – candidiasis
Salivary changes
Ulcer - Hemorrhage
Late Effects
 Mucositis
 Osteoredionecrosis
 Radiation caries
 Xerostomia
 Dysphagia
Mucositis
 Etiology
 Multifactorial – habit related to dose of radiation
 Hyperfractionated radiotherapy show more side effects
 6 months interval following radiation therapy complete
ulcer healing.
Mechanism of Mucositis Development
 In 1998, Sonis proposed that mucositis is related to direct
and indirect cytotoxocity,
 Radiation therapy has a direct cytotoxicity - local tissue
cytokine and immune activity, and bacterial colonization
of ulcerative lesion
 Chemotherapy causes Myelosuppression in which
neutropenia and thrombocytopenia can influence
mucositis indirectly through secondary infection and
hemorrhage
 Another proposed mechanism involves the alteration of
salivary immunoglobulins, proteins, electrolytes, and
nonspecific host defense in saliva
Mucositis Mangement
General Mouth Care
Cryotherapy – use of ice chips
Xerostomia – Pilocarpine
Cytoprotective Agent – Amifostine
Mucositis Pain Induced by Radiation Therapy: Prevalence, Severity, and Use of Self-Care Behaviors
Wong P.C, Dodd M V, Miaskowski C, Journal of Pain and Symptom Management Vol. 32 No. 1 July
2006
Osteoradionecrosis
 Regaud 1920 – described osteoradionecrosis as side effect of
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radiation therapy
Definition – as a condition in which devitalized, irradiated
bone becomes exposed through a wound in the overlying skin
or mucosa. Such a wound must not be caused by tumor
recurrence, or by tumor necrosis during radiation therapy, and
it must persist without healing for 3 to 6 months
ORN clinical features – intolerable pain, fracture of bone,
sequestration of devitalized bone and fistulas, which makes
chewing impossible.
Early stage ORN (< 2 years) after radiotherapy is seen with
high radiation dose of more than 70 Gy and/or concomitant
surgical and/or radiation trauma
Late stage ORN is observed several years after radiotherapy
and is related to trauma within the hypo vascular – hypo
cellular hypoxic tissue
Facts regarding osteoradionecrosis
General conditions and personal hygiene.
(1) it is rare when doses of less than 60Gy are used at 1,000
cGy or less per week
(2) it is more likely to occur if brachytherapy is used instead
of or in addition to external beam therapy
(3) the mandible is affected far more frequently than is the
maxilla or the other bones of the head and neck
(4) dental extractions, surgery, or other types of trauma
frequently precede (happen before) the onset of
osteoradionecrosis
(5) osteoradionecrosis is a problem of impaired wound
healing, not an infection like osteomyelitis, although there
may be secondary infection.
Management Of Osteoradionecrosis
 Oral/intravenous administration of antibiotics in combination
with surgical procedures immediately after extraction.
 Particular care must be taken with extraction techniques, dental
hygiene, fluoride devices for tooth protection, adequate healing
time for teeth extracted before radiotherapy an exact pre-radiation
planning and a careful post-surgical wound treatment.
 Hyper Baric Oxygen treatment has been used to promote
revascularization of the irradiated tissues.
 This therapy alone seems to be ineffective in ORN because it is not able to
revitalize dead bone hence surgical removal of devitalised bone followed by
HBO is helpful.
Xerostomia
 Decrease in saliva usually seen after 2 weeks.
 Symptomatic Grading of Xerostomia
 Grade 0: no effect on speech and food intake.
 Grade 1: some effort required for speech and food intake but
not requiring liquid for taking dry food.
 Grade 2: discomfort on speech and food intake requiring liquid
for taking dry food.
 Grade 3: requiring liquid for regular conversation, presence of
dried, coated oral mucosa.
Does radiation dose to the salivary glands and oral cavity predict patient-rated
xerostomia and sticky saliva in head and neck cancer patients treated with curative
radiotherapy? Jellemaa A P, Doornaerta P, Slotmana B, Leemansb C, Johannes A.,
Langendijka,c Radiotherapy and Oncology 77 (2005) 164–171
XEROSTOMIA MANAGEMENT
 Pilocarpine – is the drug of choice
 The response of salivary glands to pilocarpine requires
residual functional salivary gland tissue
Other Methods –
 Frequent sipping of water
 Artificial salivary supplements (oral balance)
 Maintenance of oral hygiene
 Amifostine
Amifostine – Most Important Drug
 IV infusion prior to radiotherapy each time - doses
200 mg/m2 and 340 mg/m2
 Has protective effect on the salivary glands due to high
uptake and retention of amifostine and its metabolites in
the salivary glands
 Adverse effects seen are – vomiting, allergic reaction,
severe anaphylactic reaction which can be decreased
by subcutaneous application
 In patients who undergo chemotherapy adverse
effects are more.
Serious adverse effects of amifostine during radiotherapy in head and neck cancer
patients Radesa D, Fehlauera F, Bajrovica A, Mahlmannb B, Richterb E, Albertia
W Radiotherapy and Oncology 70 (2004) 261–264h
Radiation Caries
Radiation caries
 Rampant form of dental decay.
 Highly destructive
 Evident within 3 months of
radiation therapy.
Etiology:
 changes in salivary gland & saliva
composition.
 Reduced cleansing action of saliva
 debris accumulate.
Clinical features
Seen on plaque forming
surfaces & areas of exposed
dentin
Types:
Type 1: widespread
superficial lesion- buccal,
occlusal, incisal, & palatal
surfaces.- common
Type 2: involves cementum, & dentin
in cervical region.- loss of crown.
Type 3: dark pigmentation of entire
crown, incisal edge markedly worn.
Areas below contact pt affected
last by caries
Striking feature – rapid progression
but rarely associated acute pain.
Decrease in pulpal responsedecrease in vascularity, fibrosis, &
atrophy of pulp.
Management
 Oral hygiene instructions
 Education
 Avoidance of dietary sucrose
Methods to control:
 Daily application of viscous topical 1% neutral NaF gel
 Combination of dental restorative procedures, oral
hygiene, topical application- best result.
 Pt co-operation.
 Gross decay- extraction advised.
Hyperbaric Oxygen Therapy
 It was believed that ORN was a chronic infective osteomyelitis
 HBO has adjuvant(joint) role in the treatment of infection in
this situation.
 The rationale for using HBO is that intermittent elevation of
tissue oxygen tension stimulates collagen synthesis and
fibroblastic proliferation.
 contra-indications to HBO are:
1. Optic neuritis
2. existing neoplasia.
Indications for HBO
1 Radiation necrosis of bone and soft tissues
2 Healing of hypoxic wounds
3 Compromised skin grafts and flaps
4 Chronic refractory osteomyelitis
5 Crush injuries and traumatic ischaemia
6 Diabetic ulcers
7 Carbon monoxide and cyanide poisoning
Treatment with HBO is measured by the number of ‘DIVES’ in the chamber. A ‘DIVE’
consists of breathing 100% pure oxygen at 2 atm of pressure.
The ‘DIVE’ lasts approximately 90 min including compression and
decompression.
Clinical Hyperbaric Unit (CHU)
Hyperbaric Therapy Unit (HTU)
Any Questions???
 Thank You