|Year : 2015 | Volume
| Issue : 2 | Page : 134-138
Oral complications in an irradiated patient: A case report with review of the literature
Abdulla Mufeed1, Reshma V Jameela1, Johnson K Isaac1, Vadi Vazhagan1, Abdul Shameem2
1 Department of Oral Medicine and Radiology, MES Dental College, Perinthalmanna, Kerala, India
2 Department of Conservative Dentistry and Endodontics, MES Dental College, Perinthalmanna, Kerala, India
|Date of Web Publication||20-Apr-2015|
Department of Oral Medicine and Radiology, MES Dental College, Perinthalmanna, Malappuram - 679 321, Kerala
The harmful effects of radiation and chemotherapy are well-documented, and lots of research has been carried out to minimize the hazardous effects. By which, we have moved ahead in this regard and now able to deliver the treatment with minimal morbidities. However, the follow-up of patients during the postradiation/chemotherapy is usually dependent on general practitioners in most developing countries. The knowledge and awareness of these health issues among the medical and dental general practitioners are deficient. We present here, one of our patients who encountered a multitude of oral problems secondary to radio-chemotherapy along with a brief discussion.
Keywords: Oral mucositis, osteoradionecrosis, radiation caries, radiation hazards
|How to cite this article:|
Mufeed A, Jameela RV, Isaac JK, Vazhagan V, Shameem A. Oral complications in an irradiated patient: A case report with review of the literature. SRM J Res Dent Sci 2015;6:134-8
|How to cite this URL:|
Mufeed A, Jameela RV, Isaac JK, Vazhagan V, Shameem A. Oral complications in an irradiated patient: A case report with review of the literature. SRM J Res Dent Sci [serial online] 2015 [cited 2020 Oct 28];6:134-8. Available from: https://www.srmjrds.in/text.asp?2015/6/2/134/155478
| Introduction|| |
Oral cavity is frequently irradiated during radiotherapy for head and neck malignancies. Mucositis, xerostomia and osteoradionecrosis are the most common oral complications of the nonsurgical therapy of cancer. Mucositis is the common sequel of radiotherapy and chemotherapy in patients with cancer. This article presents a case of simultaneous occurrence of oral mucositis, radiation caries, and osteoradionecrosis in a patient underwent chemo-radiotherapy for a malignancy of esophagus.
| Case report|| |
A 52-year-old male patient reported to our institute with a complaint of pain in the lower front region of the jaw since 1-month. The pain was intermittent, dull aching type and localized in nature. He complained of discomfort on taking food. Patient gave history of extraction of lower front teeth 1-month back in a private clinic due to pain and swelling.
His medical history revealed a surgical intervention for carcinoma of esophagus within the last year, followed by radiation and chemotherapy. The details of the treatment were not available to us. However, he stated that he received a course of radiation 5 months back. He was also under psychiatric treatment. His family history was noncontributory. The patient appeared to be in overall good physical health. The vital signs were within the normal range.
Extra-oral examination revealed alopecia on the lower half of face [Figure 1]. Intraoral examination showed erythematous areas of entire oral mucosa with few areas of erosion [Figure 2] and [Figure 3]. Dorsum of tongue appeared depapillated. The mucosa was dry, partly sticky, and nontender on palpation. There were exposed sockets in relation to lower anteriors with denuded mucosa [Figure 4]. The areas in relation to 31, 32, 41, 42, and 43 were covered with slough and debris. Palpable bony projections were found in the same area and were tender. Tooth 14, 15 and 18 were missing. The remaining teeth in the maxillary and mandibular arch were discolored and decayed with considerable loss of tooth structure and [Figure 2] and [Figure 3].
|Figure 1: Alopecia of lower half of face corresponding to radiation field|
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Based on the history and the clinical features, a provisional diagnosis of osteoradionecrosis of mandibular anterior region, radiation-induced mucositis and radiation caries were considered.
Intraoral periapical radiograph in relation to mandibular anterior region showed the presence of root stumps in relation to 42. The teeth in relation to 31, 32, and 41 were also confirmed to be missing. The edentulous region showed radiopaque bony spicules between the diffuse radiolucency suggestive of destruction of trabaculae [Figure 5]. Dental panoramic radiograph confirmed the same findings and also revealed the presence of multiple decayed teeth in the both maxillary and mandibular arches [Figure 6]. Radiographic evidence supported the diagnosis of osteoradionecrosis and radiation caries.
Debridement of the sockets and irrigation with saline were done. Patient was discharged with systemic antibiotics (amoxicillin 500 mg TID for 5 days), chlorhexidine mouth rinse and meticulous oral hygiene instructions. During the follow-up review after 1-week, the mucosa appeared almost normal with few areas of redness [Figure 7] and the alveolus in the mandibular anterior region demonstrated initial signs of resolution [Figure 8]. As the bone is less vascular, total healing is expected to take 3 weeks or more.
|Figure 5: Intra oral periapical radiograph showing root fragments, bony spicules and irregular trabaculae|
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|Figure 6: Orthopantomogram demonstrating generalized tooth destruction and bony changes|
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| Discussion|| |
Radiotherapy plays an important role in the management of head and neck malignancy. It is widely used as a primary treatment modality, as an adjunct to surgery, in combination with chemotherapy, or as palliation in cases of invasive head and neck cancer. Most patients with head and neck malignancies receive a dose between 50 and 70 Gy. A dose of 2 Gy per fraction is usually given once daily over a period of 5-7 weeks, 5 days a week. 
In addition to anti-tumorogenic effects, ionizing radiation causes damage to the normal tissues located in the radiation portals. Oral complications of radiotherapy in the head and neck region are the result of the deleterious effects of radiation on salivary glands, oral mucosa, bone, dentition, masticatory musculature, and tempero mandibular joints. The clinical consequences of radiotherapy include mucositis, hyposalivation, taste loss, osteoradionecrosis, radiation caries, and trismus. All these consequences have a tremendous impact on the quality of life of the patients during and after radiotherapy. 
The adverse effects of radiotherapy can be chronologically divided into acute and late effects. Acute adverse effects are defined as changes in tissues or associated symptoms noted within 90 days from the date of initiation of radiotherapy.  The acute reactions most often encountered in radiation therapy of head and neck cancer are acute mucositis and radiation-induced skin reactions.
Late effects are defined as changes in tissue or associated symptoms that occur more than 3 months from the beginning of radiotherapy. The risk of radiation-induced late complications of various organs is highly dependent on the dose given and the treatment volume and fractionation used. Most late effects develop within the first 3 years following radiotherapy for head and neck cancer, and a few progresses beyond 3 years. Data derived from Radiation Therapy Oncology Group trials indicate that 85% of patients who received conventional radiation alone experienced some form of late toxicity. Approximately 12% suffered from grade 3 or 4 reactions, the most common of which were xerostomia, dysphagia, and laryngeal toxicity respectively.  Another possible severe late complication of head and neck radiotherapy is mandibular osteoradionecrosis
Oropharyngeal mucositis is the most common and clinically significant acute adverse effect of radiotherapy for head and neck cancer. Damage to the oral mucosa is strongly related to radiation dose, fraction size and volume of irradiated tissue, fractionation scheme, and type of ionizing irradiation.  With conventional fractionation, the first signs of mucositis normally appear during the 2 nd week of radiotherapy and progress toward the end of radiotherapy from enanthema to spotted or confluent pseudomembranous mucositis.
The acute mucosal response to radiotherapy is a result of mitotic death of epithelial cells, since the cell cycle time of the basal keratinocytes is about 4 days.  Mucositis is most severe in the soft palate, followed, in order, by the mucosa of the hypopharynx, floor of the mouth, cheek, base of the tongue, lips, and dorsum of the tongue. Patients with compromised oral mucous membranes secondary to alcoholism and/or excessive smoking exhibit the most severe mucosal changes. 
Recovery occurs within 2.5-3 weeks after completion of radiotherapy, and within 1-month the mucosa heals in 90-95% of patients. Acute mucosal reactions cause pain, with concomitant difficulties in swallowing and speaking. Difficulties in eating may lead to worsening of the nutritional status and weight loss, and mucositis also predisposes to local and systemic infections. Severe mucositis is the most common cause for interruption of the radiotherapy course for head and neck cancer, which in turn can lead to significant loss of local tumor control probability. Since treatment options for oral mucositis are limited, prophylaxis of this debilitating complication has to be emphasized.  The therapeutic approach has a supportive and palliative character, which is aimed at alleviating symptoms and avoiding secondary complications such as dehydration, cachexia, and infection. A multitude of drugs has been evaluated successfully as a prophylactic and therapeutic agents like local anesthetics, betacarotene, antimicrobials such as chlorhexidine and povidine-iodine, cryoprotectants like amifostine and a series of cytokines. Besides pharmacological methods, scrupulous maintenance of oral hygiene plays an important role in the prevention, followed by cryotherapy, radiation shields, and soft laser treatment also have been proved to be effective. 
Patients who have not shown any degree of caries activity for years may develop dental decay and varying degrees of disintegration after irradiation. The cervical areas of the tooth are most typically affected. This condition appears to be due to the lack of saliva as well as to changes in the saliva's chemical composition. Radiation-induced dental effects primarily depend on salivary changes, but direct irradiation of teeth may also alter the organic or inorganic components in some manner, making them more susceptible to decalcification. There do not appear to be any clinical or histologic pulpal differences between noncarious human adult teeth that have been in the primary field of radiation and noncarious human adult teeth that have not.  To prevent or at least minimize radiation caries, oral hygiene must be maximal, including intensive home care and frequent office visits for examination and prophylaxis. Mouth rinsing is essential. Antiseptic mouth rinses like chlorhexidine, if it can be tolerated, are helpful in eliminating debris and controlling microbial flora. Daily applications of topical fluoride, in the form of a solution for mouth rinsing, a gel delivered by means of a tray, or paste or gel that is brushed on, are effective. , Attempts should be made to increase salivary flow by either local or systemic means. Foods and beverages containing sucrose should be avoided as much as possible. If carious lesions develop, removal and restoration should take place immediately. When indicated, appropriate use of dental X-ray imaging is in order for the monitoring of caries activity.
Osteoradionecrosis is one of the most serious complications of head and neck irradiation for cancer. Bone cells and vascularity may be irreversibly injured. Fortunately, in many cases devitalized bone fragments will sequestrate, and lesions will spontaneously heal. However, when radiation osteonecrosis is progressive, it can lead to intolerable pain or fracture and may necessitate jaw resection. The risk for developing spontaneous osteoradionecrosis is somewhat unpredictable, but it is related to the dose of radiation delivered and bone volume (usually more than 6,000 cGy). , The mandible is at higher risk than the maxilla. The risk is increased in dentulous patients, even more so if teeth within the treatment field are removed after therapy. Spontaneous bone exposure usually occurs more than 1-year after radiation is completed. The risk for osteonecrosis continues indefinitely after radiation therapy. If osteonecrosis does not progress clinically or radiographically, the usual management involves periodic observation. If flares (swelling, suppuration, pain) occur only occasionally, antibiotics are usually effective. If pain and/or flares occur too frequently or present other difficulties for the patient, surgery must be considered. Hyperbaric oxygen treatments together with surgery and antibiotics may be helpful in healing as a result of angiogenesis induced by increased oxygen.
| Conclusion|| |
Patients do experience the adverse effects of radiation and chemotherapy. Most of the adverse effects in the orofacial region can be avoided or minimized if proper maintenance be followed and care provided during the postradiation period. Advances in radiotherapy like image guided radiation therapy and intensity-modulated radiation therapy have significantly reduced the posttreatment morbidities. The patients and supporting family members should be educated regarding the possible consequences and their preventive measures. The clinicians should be aware and alert to identify such changes at an early stage. Together we can ensure them a better living.
| References|| |
Vissink A, Jansma J, Spijkervet FK, Burlage FR, Coppes RP. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med 2003;14:199-212.
Silverman S Jr. Oral cancer: Complications of therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:122-6.
Cox JD, Stetz J, Pajak TF. Toxicity criteria of the radiation therapy oncology group (RTOG) and the European organization for research and treatment of cancer (EORTC) Int J Radiat Oncol Biol Phys 1995;31:1341-6.
Trotti A. Toxicity in head and neck cancer: A review of trends and issues. Int J Radiat Oncol Biol Phys 2000;47:1-12.
Köstler WJ, Hejna M, Wenzel C, Zielinski CC. Oral mucositis complicating chemotherapy and/or radiotherapy: Options for prevention and treatment. CA Cancer J Clin 2001;51:290-315.
Epstein JB, van der Meij EH, Lunn R, Stevenson-Moore P. Effects of compliance with fluoride gel application on caries and caries risk in patients after radiation therapy for head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:268-75.
Toljanic JA, Siddiqui AA, Patterson GL, Irwin ME. An evaluation of a dentifrice containing salivary peroxidase elements for the control of gingival disease in patients with irradiated head and neck cancer. J Prosthet Dent 1996;76:292-6.
Morrish RB Jr, Chan E, Silverman S Jr, Meyer J, Fu KK, Greenspan D. Osteonecrosis in patients irradiated for head and neck carcinoma. Cancer 1981;47:1980-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]