ORAL COMPLICATIONS DURING CANCER TREATMENT: LECTURE (p. 4)

1. Careful evaluation of the periodontium and teeth with special attention to inflammatory foci and periapical lesions. The periodontal status should be maintained at top level of hygiene as well as the rest of the oral cavity. The danger of ORN increases when the healing potential of the oral tissues is threatened by lowered hygiene and microbial infection especially of periodontal origin.
2. During chemotherapy and radiation therapy periodontal management should be restricted to emergency treatment only. Extensive periodontal surgery is not recommended because of possible prolonged healing of tissues. Its is therefore essential to complete all needed periodontal treatment prior to radiation and chemotherapy.
3. Optimal oral infection control by means of chlorhexidine rinses or other antimicrobial mouth rinses.
4. Elimination of any source of traumatic irritation to soft tissues i.e. sharp teeth edges, restorations overhang, ill fitting dentures.
5. Ablation of any hypertrophic (redundant) soft tissues i.e fibroma, polyps, denture injury tumors, granulomas, etc.
6. It is always advisable to wait a minimun of 1 week to 10 days after extraction before starting radiation therapy. Whenever possible longer waiting periods (2 or 3 weeks) are preferable. All questionable teeth should be extracted prior to radiation.
7. If extractions must be done after radiation therapy the use of hyperbaric oxygen pre-extraction should be considered. When extractions are done a carefull remodeling of the alveolar bone should be effected in order to avoid protruding edges which could be starting points of osteonecrosis.
8. Topical fluoride applications with 1% Na fluoride gel for 5 minutes a day or fluoride rinses are recommended. Custom build trays for fluoride application are also recommended. These applications will fortify the enamel in order to prevent rampant caries as a consequence to xerostomia induced by salivary glands impariment after radiation.
9. Every effort should be undertaken in order to preserve teeth which will be important in supporting restorative appliances after the cancer treatment is completed.
10. A controlled diet in order to avoid foods that will facilitate plaque accumulation and caries initiation is also an important recommendation.
11. The patient should be carefully instructed in the daily maintenance of oral hygiene by means of tooth brushing, preferably with a fluoride tooth paste, flossing and control of dental plaque.
12. It is highly suggested that the patient be given written instructions to avoid mistakes and to prevent accidental damage to the soft oral tissues by brushing or flossing.
13. Patients must not use alcohol or tobacco products as these increase the irritation of oral mucosas as well as increasing the risk of new tumor development.

1. protect all anatomical structures that do not require radiation with appropiate metal shields and precisely focused radiation.
2. try to protect one or more major salivary glands in order to avoid extreme xerostomia.
3. during radiation therapy metal restorations, such as gold crowns and dental implants, can cause forward and back scatter radiation with resultant mucositis. Special buccolingual guards can be constructed to prevent this from occurring (25).
4. the total radiation dose should be limited to a maximum of 70 Gy.
5. limit the fractioned doses to a maximum of 2 Gy.