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SHORT COMMUNICATION  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 843
Radiotherapy complications and their possible management in the head and neck region


Department of Oral Pathology, KD Dental College and Hospital, Mathura, India

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Date of Submission21-Aug-2010
Date of Decision16-Jan-2011
Date of Acceptance13-May-2012
Date of Web Publication3-May-2013
 

   Abstract 

Oral complications from radiation to the head and neck or chemotherapy for any malignancy can compromise patients' health and quality of life and affect their ability to complete planned cancer treatment. For some patients the complications can be so debilitating that they may tolerate only lower doses of therapy, postpone scheduled treatments, or discontinue treatment entirely. Oral complications can also lead to serious systemic infections. Medically necessary oral care before, during, and after cancer treatment can prevent or reduce the incidence and severity of oral complications, enhancing both patient survival and quality of life. In the present article we present an overview of oral complications, and their possible management, after radiation therapy in the head-and-neck region.

Keywords: Chemotherapy, oral complications, radiation therapy

How to cite this article:
Agarwal P, Upadhyay R, Agarwal A. Radiotherapy complications and their possible management in the head and neck region. Indian J Dent Res 2012;23:843

How to cite this URL:
Agarwal P, Upadhyay R, Agarwal A. Radiotherapy complications and their possible management in the head and neck region. Indian J Dent Res [serial online] 2012 [cited 2020 Dec 4];23:843. Available from: https://www.ijdr.in/text.asp?2012/23/6/843/111293
Head-and-neck radiation patients are a significant challenge relative to both intra-therapy and post-therapy oral complications resulting from radiation therapy. Unlike the oral complications of chemotherapy, which are of relatively shorter duration and significant for only a short period (a few weeks to 2 months) after the cessation of therapy, the oral complications of head-and-neck radiation are more predictable, often more severe, and can lead to permanent tissue changes that put the patient at risk for serious chronic complications.


   Evaluation Before Treatment Top


Elimination of oral disease and implementation of oral care protocols designed to maintain optimum oral health must be a component of patient assessment and care prior to radiation therapy. During and after radiation therapy, oral management will be dictated by the specific needs of the patient, the specifics of the radiation therapy, and the presence of chronic complications caused by radiation therapy. Ongoing oral assessment and treatment of complications are essential because radiation to oral tissues typically renders patients at lifelong risk for oral complications. In addition, invasive oral procedures can cause other sequelae. Dental care typically needs to be modified as a result of underlying chronic radiation-induced tissue damage.

Patients should receive a comprehensive oral evaluation several weeks prior to initiation of high-dose upper-mantle radiation. This timing provides an appropriate interval for tissue healing in the event invasive oral procedures, including dental extractions, dental scaling/polishing, and endodontic therapy, are necessary. The goal of this evaluation is to identify teeth at significant risk for infection and/or breakdown that would ultimately require aggressive or invasive dental treatment during or after the radiation, which increases the risk of soft tissue necrosis and osteonecrosis. The likelihood of these lesions occurring post radiation increases over the patient's lifetime as the risk of significant dental disease increases. This includes restorative, periodontal, and endodontic disease. Since xerostomia is an expected complication, it is especially important that preradiation dental care strategies that can permanently reduce the impact of the complications of severe xerostomia and xerostomia decay are sought.

Drugs are being developed to try to protect normal tissues from chemotherapy or radiation damage. Amifostine, a thiol-free radical scavenger, has been shown to reduce the damage to salivary glands when given concomitantly with radiation therapy such as radioiodine for treating the thyroid gland. The adverse effects of amifostine include nausea and hypotension and, besides, the drug needs to be injected daily. [1] Xerostomia is also conservatively treated with saliva substitutes and saliva stimulants. Additionally, pilocarpine can be used; it is more effective than artificial saliva, although its effectiveness is often not seen until after 12 weeks of start of therapy.

In addition, radiation-specific issues emerge: For example, radiation injury is oral tissue-specific and is dependent on dosage and the portal of therapy. Duration of radiation-induced oral mucositis typically extends for 6-8 weeks vs the approximately 5-14 days observed in chemotherapy patients. The extended radiation treatment protocols are chiefly responsible for this difference.

The primary cause of oral cancer is tobacco use; alcohol abuse further escalates risk. It is therefore critical that the head/neck cancer patient permanently cease tobacco use. Most patients with smoking-related cancer appear motivated to quit smoking at the time of cancer diagnosis. Continued smoking substantially increases the likelihood of recurrence or occurrence of a second cancer in survivors, particularly in those who have previously received radiation therapy. A stepped-care approach to tobacco cessation is recommended, including direct physician advice to quit and provision of basic information to all patients at each contact during the first month following diagnosis, followed by more intensive pharmacologic treatment or counseling for those having difficulty quitting or remaining abstinent.


   Oral Complications of Head-and-Neck Radiation Top


The oral complications of head-and-neck radiation can be divided into two groups based on the usual time of their occurrence: Acute complications occurring during therapy or late complications occurring after radiation therapy has ended.

Acute complications include oropharyngeal mucositis, sialadenitis, xerostomia, infections (primarily candidiasis), and taste dysfunction; occasionally tissue necrosis can be seen late during therapy, but this is relatively rare.

Chronic complications include mucosal fibrosis and atrophy, xerostomia, xerostomia caries, infections (primarily candidiasis), tissue necrosis (soft tissue necrosis and osteonecrosis), taste dysfunction (dysgeusia/ageusia), muscular and cutaneous fibrosis, [2] and dysphagia. [3]


   Management of Oral Mucositis Top


Mucositis, which can be caused by radiation or chemotherapy, results from the mitotic death of the basal cells of the mucosal epithelium. Portions of the gastrointestinal tract become inflamed, and red burn-like or ulcer-like sores appear throughout the mouth [Figure 1]. The etiopathogenesis of head-and-neck radiation mucositis appears to be similar but not identical to that of mucositis caused by high-dose chemotherapy. [4],[5],[6],[7] Management strategies described for chemotherapy/hematopoietic stem cell transplantation are generally applicable to the head/neck radiation patient. [8],[9],[10] The extensive duration and severity of radiation mucositis, combined with the fact that most radiation patients are treated as outpatients, poses challenges in pain management. As mucositis severity increases and topical pain management strategies become less effective, it becomes increasingly necessary to depend on systemic analgesics to manage the pain due to oral radiation mucositis. [11] Because there is generally no bleeding risk for head-and-neck radiation patients, analgesic treatment begins with nonsteroidal anti-inflammatory drugs (NSAIDs). As pain increases, NSAIDs are combined with opioids, and patients can be made relatively comfortable. Doses for NSAIDs are titrated up to their recommended dosing ceiling; on the other hand, opioids are titrated to effective pain relief. Systemic analgesics are given by the clock to achieve steady-state blood levels to provide adequate pain relief. Additionally, adjunctive medications are given to provide adjuvant analgesia and manage the side effects of NSAIDs and opioids. Zinc supplementation used with radiation therapy may improve mucositis and dermatitis. [12] The use of alcohol-free povidone-iodine mouthwash can reduce the severity, and delay the onset, of oral mucositis due to antineoplastic radiation therapy. [13]
Figure 1: Oral mucositis involving the buccal mucosa following radiation therapy

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   Early Infections Top


Candidiasis is the most common clinical infection of the oropharynx in irradiated patients. Patients receiving head-and-neck radiation are frequently colonized with Candida, as demonstrated by an increase in quantitative counts and rates for clinical infection. [14] Candidiasis may exacerbate the symptoms of oropharyngeal mucositis [Figure 2].
Figure 2: Candida infection following therapy

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Treatment of oral candidiasis in the radiation patient has primarily utilized topical antifungals such as nystatin and clotrimazole. Compliance can be compromised secondary to oral mucositis, nausea, pain, and difficulty in dissolving nystatin pastilles and clotrimazole troches. Use of systemic antifungals, including ketoconazole and fluconazole, to treat oral candidiasis has proved effective and may have advantages over topical agents for patients experiencing mucositis.

Bacterial infections may also occur early in the course of head-and-neck radiation and, after appropriate diagnosis (i.e., culture and sensitivity tests), should be treated with antibiotics. Herpesvirus infections may also occur in patients who are seropositive prior to head-and-neck radiation. [15],[16]


   Taste Dysfunction Top


As oral and pharyngeal mucosa are exposed to radiation, taste receptors become damaged and taste discrimination becomes increasingly compromised. [17],[18] After several weeks of radiation it is common for patients to complain of loss of taste sensation. It will generally take upwards of 6-8 weeks after the end of radiation therapy for taste receptors to recover and become functional. Zinc sulfate supplements (220 mg two or three times a day) have been reported to help with recovery of the sense of taste. [19],[20],[21]


   Late Reactions Top


Late oral complications of radiation therapy are chiefly a result of chronic injury to vasculature, salivary glands, mucosa, connective tissue, and bone. [19],[22],[23] The types and severity of these changes are directly related to radiation dosimetry, including total dose, fraction size, and duration of treatment. Mucosal changes include epithelial atrophy, reduced vascularization, and submucosal fibrosis. These changes lead to an atrophic, friable barrier. Fibrosis involving muscle, dermis, and the temporomandibular joint results in compromised oral function. Salivary tissue changes include loss of acinar cells, alteration in duct epithelium, fibrosis, and fatty degeneration. Compromised vascularization and remodeling capacity of bone leads to risk for osteonecrosis.


   Caries Top


Dental caries risk increases secondary to a number of factors, including shifts to a cariogenic flora, reduced concentrations of salivary antimicrobial proteins, and loss of mineralizing components. [19] Treatment strategies must be directed at each component of the caries process. Optimal oral hygiene must be maintained. Xerostomia should be managed whenever possible via saliva substitutes or replacements. Caries resistance can be enhanced with the use of topical fluorides and/or remineralizing agents. Efficacy of topical products may be enhanced by increasing contact time on the teeth by application using vinyl carriers. Patients not able to effectively comply with the use of fluoride trays should be instructed to use brush-on gels and rinses.

Increased colonization with  Streptococcus mutans Scientific Name Search obacillus species increases caries risk. Culture data can be useful in defining the level of risk in relation to colonization patterns. Topical fluorides or chlorhexidine rinses may lead to reduced levels of S mutans but not of Lactobacilli. Due to the possibility of adverse drug interactions, fluoride and chlorhexidine dosing should be separated by several hours.

Remineralizing agents, which are high in calcium, phosphate and fluoride, have demonstrated salutary in vitro and clinical effects. Their effects may be enhanced by delivering the drug via customized vinyl carriers. This approach extends the contact time of active drug with tooth structure, which leads to increased uptake into enamel.


   Tissue Necrosis Top


Necrosis and secondary infection of previously irradiated tissue is a serious complication for patients who have undergone radiation for head-and-neck tumors. [19] Acute effects typically involve the oral mucosa. Chronic changes involving bone and mucosa are a result of the process of vascular inflammation and scarring that, in turn, result in hypovascular, hypocellular, and hypoxic changes. Infection secondary to tissue injury and osteonecrosis confounds the process [Figure 3].
Figure 3: Osteoradionecrosis involving the mandible

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Soft tissue necrosis can involve any mucosal surface in the mouth, though nonkeratinized surfaces appear to be at moderately higher risk. Trauma and injury is often associated with nonhealing soft tissue necrotic lesions, though spontaneous lesions are also reported. Soft tissue necrosis begins as an break in the mucosal surface that progressively increases in area and depth. Pain will generally become more prominent as soft tissue necrosis becomes worse. Secondary infection is a risk.

As noted above, risk for necrosis is directly related to radiation dose and volume of tissue irradiated. The unilateral vascular supply to each half of the mandible results in osteonecrosis more frequently involving the mandible vs the maxilla. Presenting clinical features include pain, diminished or complete loss of sensation, fistula, and infection. Pathologic fracture can occur as the compromised bone is unable to appropriately undergo repair at the involved sites. Risk for tissue necrosis is in part related to trauma or oral infection; however, idiopathic cases can also occur. Patients who have received high-dose radiation to the head and neck are at risk for osteonecrosis for life, with an overall risk of approximately 15%.

Ideally, osteonecrosis management centers on prevention, which begins with comprehensive oral and dental care prior to radiation. The dentition, periodontium, periapices, and mucosa should be thoroughly examined to identify oral disease that could lead to serious odontogenic, periodontal, or mucosal infections and necessitate surgical therapy post radiation. Oral disease should be eliminated prior to cancer therapy. Dentition that exhibits poor prognosis and is within high-dose fields should be extracted prior to radiation therapy. Ideally, at least 7-14 days should be allowed for healing prior to initiation of radiation; some have suggested allowing up to 21 days. The surgical technique should be as atraumatic as possible and should utilize primary wound closure.

Patients who develop osteonecrosis should be comprehensively managed, with elimination of trauma, avoidance of removable dental prosthesis if the denture-bearing area is within the osteonecrotic field, assurance of adequate nutritional intake, and motivation to discontinue of tobacco and alcohol use. Topical antibiotics (e.g., tetracycline) or antiseptics (e.g., chlorhexidine) may contribute to wound resolution. Wherever possible, coverage of the exposed bone with mucosa should be achieved. Analgesics for pain control are often effective. Local resection of bone sequestrae may be possible.

Hyperbaric oxygen therapy (HBO) is recommended for the management of osteonecrosis, although it has not been universally accepted. HBO has been reported to increase oxygenation of irradiated tissue, promote angiogenesis, and enhance osteoblast repopulation and fibroblast function. HBO is usually prescribed as 20-30 dives at 100% oxygen and 2-2.5 atmospheres of pressure. If surgery is needed, 10 dives of postsurgical HBO therapy are recommended. Unfortunately, HBO technology is not always accessible to patients who might benefit because of lack of available units and the high price of care.

Partial mandibulectomy may be necessary in severe cases of osteonecrosis. The mandible can be reconstructed for esthetics and function. A multidisciplinary cancer team, including oncologists, oncology nurses, maxillofacial prosthodontists, general dentists, hygienists, and physical therapists, is appropriate for management of these patients.


   Dysfunction of the Jaws Top


Musculoskeletal syndromes may develop secondary to radiation and surgery. Lesions include soft tissue fibrosis, surgically-induced mandibular discontinuity, and parafunctional habits associated with the emotional stress caused by cancer and its treatment. Patients can be instructed in physical therapy interventions, including mandibular stretching exercises as well as use of prosthetic aids designed to reduce the severity of fibrosis. It is important that these approaches be instituted prior to trismus development. If clinically significant changes develop, several approaches, including stabilization of occlusion, trigger point injection and other pain management strategies, muscle relaxants, and/or tricyclic medications can be considered.

 
   References Top

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2.Vera-Llonch M, Oster G, Hagiwara M, Sonis S. Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Cancer 2006;106:329-36.  Back to cited text no. 2
    
3.Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, et al. Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 2009;73:410-5.  Back to cited text no. 3
    
4.Sonis ST. Mucositis as a biological process: A new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol 1998;34:39-43.  Back to cited text no. 4
    
5.Peterson DE. Research advances in oral mucositis. Curr Opin Oncol 1999;11:261-6.  Back to cited text no. 5
    
6.Sonis ST, Peterson DE, McGuire DB, Williams DA. Prevention of mucositis in cancer patients. J Natl Cancer Inst Monogr 2001;29:1-2.  Back to cited text no. 6
    
7.Barasch A, Peterson DE. Risk factors for ulcerative oral mucositis in cancer patients: Unanswered questions. Oral Oncol 2003;39:91-100.  Back to cited text no. 7
    
8.Dose AM. The symptom experience of mucositis, stomatitis, and xerostomia. Semin Oncol Nurs 1995;11:248-55.  Back to cited text no. 8
    
9.Demarosi F, Bez C, Carrassi A. Prevention and treatment of chemo- and radiotherapy-induced oral mucositis. Minerva Stomatol 2002;51:173-86.  Back to cited text no. 9
    
10.Shih A, Miaskowski C, Dodd MJ, Stotts NA, MacPhail L. A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer. Oncol Nurs Forum 2002;29:1063-80.  Back to cited text no. 10
    
11.Wong PC, Dodd MJ, Miaskowski C, Paul SM, Bank KA, Shiba GH, et al. Mucositis pain induced by radiation therapy: Prevalence, severity, and use of self-care behaviors. J Pain Symptom Manage 2006;32:27-37.  Back to cited text no. 11
    
12.Lin LC, Que J, Lin LK, Lin FC. Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: A double-blind, randomized study. Int J Radiat Oncol Biol Phys 2006;65:745-50.  Back to cited text no. 12
    
13.Madan PD, Sequeira PS, Shenoy K, Shetty J. The effect of three mouthwashes on radiation-induced oral mucositis in patients with head and neck malignancies: A randomized control trial. J Cancer Res Ther 2008;4:3-8.  Back to cited text no. 13
    
14.Epstein JB, Freilich MM, Le ND. Risk factors for oropharyngeal candidiasis in patients who receive radiation therapy for malignant conditions of the head and neck. Oral Surg Oral Med Oral Pathol 1993;76:169-74.  Back to cited text no. 14
    
15.Oakley C, Epstein JB, Sherlock CH. Reactivation of oral herpes simplex virus: Implications for clinical management of herpes simplex virus recurrence during radiotherapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:272-8.  Back to cited text no. 15
    
16.Epstein JB, Gorsky M, Hancock P, Peters N, Sherlock CH. The prevalence of herpes simplex virus shedding and infection in the oral cavity of seropositive patients undergoing head and neck radiation therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:712-6.  Back to cited text no. 16
    
17.Nelson GM. Biology of taste buds and the clinical problem of taste loss. Anat Rec 1998;253:70-8.  Back to cited text no. 17
    
18.Zheng WK, Inokuchi A, Yamamoto T, Komiyama S. Taste dysfunction in irradiated patients with head and neck cancer. Fukuoka Igaku Zasshi 2002;93:64-76.  Back to cited text no. 18
    
19.Silverman S Jr. Complications of treatment. In: Silverman S Jr, editor. Oral Cancer. 5 th ed. Hamilton, Canada: BC Decker Inc; 2003. pp. 113-28.  Back to cited text no. 19
    
20.Ripamonti C, Zecca E, Brunelli C, Fulfaro F, Villa S, Balzarini A, et al. A randomized, controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer 1998;82:1938-45.  Back to cited text no. 20
    
21.Silverman JE, Weber CW, Silverman S Jr, Coulthard SL, Manning MR. Zinc supplementation and taste in head and neck cancer patients undergoing radiation therapy. J Oral Med 1983;38:14-6.  Back to cited text no. 21
    
22.Myers RA, Marx RE. Use of hyperbaric oxygen in postradiation head and neck surgery. NCI Monogr 1990;151-7.  Back to cited text no. 22
    
23.Epstein JB, Wong FL, Stevenson-Moore P. Osteoradionecrosis: Clinical experience and a proposal for classification. J Oral Maxillofac Surg 1987;45:104-10.  Back to cited text no. 23
    

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Correspondence Address:
Pankaj Agarwal
Department of Oral Pathology, KD Dental College and Hospital, Mathura
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111293

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    Abstract
    Evaluation Befor...
    Oral Complicatio...
    Management of Or...
   Early Infections
   Taste Dysfunction
   Late Reactions
   Caries
   Tissue Necrosis
    Dysfunction of t...
    References
    Article Figures

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