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BY:
ADWITI VIDUSHI
B.D.S FINAL YEAR
GUIDED BY :
DR. SHALU RAI
DR. DEEPANKAR MISRA
DR. VIKASH RANJAN
DR. MUKUL PRABHAT
DR. MANSI KHATRI
CONTENTS
 Rationale
 Oral Mucous Membrane
 Taste Buds
 Salivary Glands
 Teeth
 Radiation Caries
 Bone
 Musculature
RATIONALE
 Oral cavity is exposed to large doses of radiation when
radiation therapy is used in the treatment of oral cancer.
 Radiation therapy for malignant lesions in oral cavity
indicated when Lesion radiosensitive/advanced
/deeply invasive & cannot be approached surgically.
 Radiation treatment administered as many small doses
(fractions).
 Typically 2 Gy delivered daily for weekly exposure of 10
Gy.
 Radiotherapy course continues for 6-7 weeks until total
60-70 Gy administered.
 The complications (deterministic effects) of a course of
radiotherapy on the normal oral tissues result only from
therapeutic exposures, not from radiation levels used for
diagnostic imaging.
Effects of radiation on oral tissues
ORAL MUCOUS MEMBRANE
 MUCOSITIS- Reddening and inflammation of oral mucosa
 1st Sign of mucositis – end of second week of therapy.
 ATROPHY OF RADIOSENSITIVE BASAL LAYER
 FORMATION OF WHITE-YELLOW PSEUDOMEMBRANE
 SLOUGHING OF MUCOSA
 SECONDARY INFECTION DUE TO Candida albicans
(common complication)
 HEALING (After about two months)
Radiation induced mucositis is initiated by direct injury to basal
epithelial cells and the cells in the underlying tissue.DNA
strands breaks and results into cell death or injury.
Clinical Features
 Reddish inflamed mucosa
 Areas of white pseudo
membrane
 Areas where oral epithelium is
separated from underlying
connective tissue
 Sores in mouth, gums and
tongue
 Dysphagia
 Ulcers due to radiation
necrosis
 Complications in denture
wearing
WHO MUCOSITIS SCALE:
1.Soreness/ Erythema
2.Erythema,ulcers but patient is able to eat solid.
3.Ulcers, requires liquid diet.
4.Food administration is not possible orally.
Management
 Good oral hygiene
 Avoid spicy, hard, acidic and hot food and beverages
 TOPICAL ANESTHETICS (required at mealtimes)
 -Lidocaine (ointment, sprays)
 -Benzocaine (gels, sprays)
 ANALGESICS
 -Opioid drugs
TASTE BUDS
 Taste buds sensitive to radiation
 Extensive degeneration of normal histological
architecture of taste buds caused by therapeutic doses
 2nd-3rd week of Radiotherapy Patients notice loss of
taste acuity
 Posterior two-thirds affects bitter and acid flavours
 Anterior third affects sweet and salty flavours
 Taste acuity decreases by a factor of 1000 to 10,000
during course of Radiotherapy
 Alterations in saliva due to radiation changes in
taste perception
 Taste loss is reversible , recovery takes 60-120 days
Effects of radiation on oral tissues
SALIVARY GLANDS
 Major salivary glands exposed to 20-30 Gy
 Parenchymal component of salivary glands
radiosensitive
 Marked decrease in salivary flow first few weeks
after initiation of radiotherapy.
 Extent of reduced flow dose dependent
may reach zero at 60 Gy.
 Mouth dry (xerostomia) tenderness
 Difficulty and pain in swallowing
 Composition of saliva affected.
 Increased concentration of sodium, chloride,
calcium, magnesium ions and proteins
 Loss of lubricating properties of saliva
 Serous acini are more affected as they are more
radiosensitive than mucous.
(Parotid>Submandibular/Sublingual)
 Viscosity of saliva increases.
 pH of saliva decreases Decalcification of
enamel
 Compensatory hypertrophy of the salivary gland
xerostomia subsides 6-12 months after
therapy
 Xerostomia persisting beyond a year less likely
to return to normal
Inflammatory response after initiation of therapy
Loss of acini and ducts
Progressive fibrosis
Adiposis
Loss of fine vasculature
Parenchymal degeneration
Effects of radiation on oral tissues
TEETH
 Adult teeth resistant to radiation effects
 Developing teeth retarded root development,
dwarf teeth, failure to form one or more teeth
 Tooth bud Destruction
 Calcified teeth Inhibited cellular differentiation
Malformation Arrested general growth
 Pulp decreased vascularity reduced cellularity
Tooth prone to pulpitis
 Eruptive mechanism radiation resistant. Irradiated
teeth with altered root formation erupt, even if rootless
 Severity of damage dose dependent
RADIATION CARIES
 Rampant form of dental decay that may occur in
individuals who receive a course of radiotherapy that
includes exposure of the salivary glands
 Lesions occur secondary to changes in the salivary glands
and saliva due to :
 -decreased salivary flow
 -decreased pH of saliva
 -increased viscosity of saliva
 -decreased lubricating properties of saliva
 Patients receiving radiation therapy have increased
Streptococcus mutans, Lactobacillus & Candida
 Destruction is seen with doses >30 Gy and is pronounced
when the teeth receive >60 Gy
Clinically, 3 types of Radiation Caries seen :
 Widespread superficial lesions attacking buccal,
occlusal incisal, & palatal surfaces
 Primarily involving cementum and dentin in the
cervical areas. Lesion progresses around tooth
circumference Loss of crown
 Dark pigmentation of entire crown
 Combination of all these lesions appear in some
patients
Effects of radiation on oral tissues
MANAGEMENT :
 -Topical application of 1 %
neutral sodium fluoride (viscous
gel) in custom made applicator
trays
 -Combination of restorative
dental procedures, good oral
hygiene, diet restricted in
cariogenic food and topical
application of Sodium fluoride
 -Grossly decayed teeth or teeth
with periodontal involvement to
be extracted before irradiation
BONE
 Mandible or maxilla often irradiated during treatment
of cancers in oral region
 Damage to fine vasculature
 Primary damage to mature bone
 Irradiation
 normal marrow replaced with fatty marrow and
fibrous connective tissue
 marrow tissue becomes hypovascular, hypoxic,
hypocellular.
 Degree of mineralization reduced
 Brittleness or altered from normal bone
 Endosteum becomes atrophic : lacks osteoblastic
osteoclastic activity
OSTEORADIONECROSIS . :-
 Definition -Inflammatory condition of bone that occurs after bone
has been exposed to therapeutic doses of radiation given for a
malignancy of the head and neck region.
Decreased vascularity of mandible
infection by microorganisms from the oral cavity
Radiation-induced breakdown of the oral mucous membrane
mechanical damage to the weakened oral mucous membrane
(eg.denture sore /extraction/periodontal lesion/radiation caries)
Bone Infection
Non-healing wound in irradiated bone
difficult to treat.
Effects of radiation on oral tissues
Clinical Features
 Mandible >Maxilla
 Temporal bone also
affected.
 Time period- 7.5 years-20
years
 Extra and intra oral fistula
 Parasthesia and
anaesthesia
 Pathological fracture
 TYPES:
Early, trauma induced
Spontaneous, without any trauma
Late, trauma induced
AREA OF EXPOSED MANDIBLE AFTER RADIOTHERAPY
LOSS OF ORAL MUCOSA
DESTRUCTION OF IRRADIATED BONE RESULTING FROM INFECTION
TREATMENT
 Debridement
 Antibiotic- 2 million units
 Supportive therapy
 Analgesics- narcotic and non-narcotic drugs
 Good oral hygiene
 Bone resection.
 Hyperbaric oxygen therapy
Effects of radiation on oral tissues
MUSCULATURE
 Inflammation and fibrosis of musculature due to radiation
 Contracture and trismus of muscles of mastication
 Masseter or pterygoid usually involved
 Restriction in mouth opening starts about 2 months after
completion of radiotherapy
 Management : Physiotherapy may help in increasing
opening distance
REFERENCES
 ORAL RADIOLOGY (PRINCIPLES AND INTERPRETATION) –
WHITE & PHAROAH
 ESSENTIALS OF ORAL AND MAXILLOFACIAL RADIOLOGY –
FRENY R KARJODKAR
Effects of radiation on oral tissues

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Effects of radiation on oral tissues

  • 1. BY: ADWITI VIDUSHI B.D.S FINAL YEAR GUIDED BY : DR. SHALU RAI DR. DEEPANKAR MISRA DR. VIKASH RANJAN DR. MUKUL PRABHAT DR. MANSI KHATRI
  • 2. CONTENTS  Rationale  Oral Mucous Membrane  Taste Buds  Salivary Glands  Teeth  Radiation Caries  Bone  Musculature
  • 3. RATIONALE  Oral cavity is exposed to large doses of radiation when radiation therapy is used in the treatment of oral cancer.  Radiation therapy for malignant lesions in oral cavity indicated when Lesion radiosensitive/advanced /deeply invasive & cannot be approached surgically.  Radiation treatment administered as many small doses (fractions).  Typically 2 Gy delivered daily for weekly exposure of 10 Gy.  Radiotherapy course continues for 6-7 weeks until total 60-70 Gy administered.  The complications (deterministic effects) of a course of radiotherapy on the normal oral tissues result only from therapeutic exposures, not from radiation levels used for diagnostic imaging.
  • 5. ORAL MUCOUS MEMBRANE  MUCOSITIS- Reddening and inflammation of oral mucosa  1st Sign of mucositis – end of second week of therapy.  ATROPHY OF RADIOSENSITIVE BASAL LAYER  FORMATION OF WHITE-YELLOW PSEUDOMEMBRANE  SLOUGHING OF MUCOSA  SECONDARY INFECTION DUE TO Candida albicans (common complication)  HEALING (After about two months)
  • 6. Radiation induced mucositis is initiated by direct injury to basal epithelial cells and the cells in the underlying tissue.DNA strands breaks and results into cell death or injury.
  • 7. Clinical Features  Reddish inflamed mucosa  Areas of white pseudo membrane  Areas where oral epithelium is separated from underlying connective tissue  Sores in mouth, gums and tongue  Dysphagia  Ulcers due to radiation necrosis  Complications in denture wearing
  • 8. WHO MUCOSITIS SCALE: 1.Soreness/ Erythema 2.Erythema,ulcers but patient is able to eat solid. 3.Ulcers, requires liquid diet. 4.Food administration is not possible orally.
  • 9. Management  Good oral hygiene  Avoid spicy, hard, acidic and hot food and beverages  TOPICAL ANESTHETICS (required at mealtimes)  -Lidocaine (ointment, sprays)  -Benzocaine (gels, sprays)  ANALGESICS  -Opioid drugs
  • 10. TASTE BUDS  Taste buds sensitive to radiation  Extensive degeneration of normal histological architecture of taste buds caused by therapeutic doses  2nd-3rd week of Radiotherapy Patients notice loss of taste acuity  Posterior two-thirds affects bitter and acid flavours  Anterior third affects sweet and salty flavours  Taste acuity decreases by a factor of 1000 to 10,000 during course of Radiotherapy  Alterations in saliva due to radiation changes in taste perception  Taste loss is reversible , recovery takes 60-120 days
  • 12. SALIVARY GLANDS  Major salivary glands exposed to 20-30 Gy  Parenchymal component of salivary glands radiosensitive  Marked decrease in salivary flow first few weeks after initiation of radiotherapy.  Extent of reduced flow dose dependent may reach zero at 60 Gy.  Mouth dry (xerostomia) tenderness  Difficulty and pain in swallowing
  • 13.  Composition of saliva affected.  Increased concentration of sodium, chloride, calcium, magnesium ions and proteins  Loss of lubricating properties of saliva  Serous acini are more affected as they are more radiosensitive than mucous. (Parotid>Submandibular/Sublingual)
  • 14.  Viscosity of saliva increases.  pH of saliva decreases Decalcification of enamel  Compensatory hypertrophy of the salivary gland xerostomia subsides 6-12 months after therapy  Xerostomia persisting beyond a year less likely to return to normal
  • 15. Inflammatory response after initiation of therapy Loss of acini and ducts Progressive fibrosis Adiposis Loss of fine vasculature Parenchymal degeneration
  • 17. TEETH  Adult teeth resistant to radiation effects  Developing teeth retarded root development, dwarf teeth, failure to form one or more teeth  Tooth bud Destruction  Calcified teeth Inhibited cellular differentiation Malformation Arrested general growth  Pulp decreased vascularity reduced cellularity Tooth prone to pulpitis  Eruptive mechanism radiation resistant. Irradiated teeth with altered root formation erupt, even if rootless  Severity of damage dose dependent
  • 18. RADIATION CARIES  Rampant form of dental decay that may occur in individuals who receive a course of radiotherapy that includes exposure of the salivary glands  Lesions occur secondary to changes in the salivary glands and saliva due to :  -decreased salivary flow  -decreased pH of saliva  -increased viscosity of saliva  -decreased lubricating properties of saliva  Patients receiving radiation therapy have increased Streptococcus mutans, Lactobacillus & Candida  Destruction is seen with doses >30 Gy and is pronounced when the teeth receive >60 Gy
  • 19. Clinically, 3 types of Radiation Caries seen :  Widespread superficial lesions attacking buccal, occlusal incisal, & palatal surfaces  Primarily involving cementum and dentin in the cervical areas. Lesion progresses around tooth circumference Loss of crown  Dark pigmentation of entire crown  Combination of all these lesions appear in some patients
  • 21. MANAGEMENT :  -Topical application of 1 % neutral sodium fluoride (viscous gel) in custom made applicator trays  -Combination of restorative dental procedures, good oral hygiene, diet restricted in cariogenic food and topical application of Sodium fluoride  -Grossly decayed teeth or teeth with periodontal involvement to be extracted before irradiation
  • 22. BONE  Mandible or maxilla often irradiated during treatment of cancers in oral region  Damage to fine vasculature  Primary damage to mature bone  Irradiation  normal marrow replaced with fatty marrow and fibrous connective tissue  marrow tissue becomes hypovascular, hypoxic, hypocellular.  Degree of mineralization reduced  Brittleness or altered from normal bone  Endosteum becomes atrophic : lacks osteoblastic osteoclastic activity
  • 23. OSTEORADIONECROSIS . :-  Definition -Inflammatory condition of bone that occurs after bone has been exposed to therapeutic doses of radiation given for a malignancy of the head and neck region. Decreased vascularity of mandible infection by microorganisms from the oral cavity Radiation-induced breakdown of the oral mucous membrane mechanical damage to the weakened oral mucous membrane (eg.denture sore /extraction/periodontal lesion/radiation caries) Bone Infection Non-healing wound in irradiated bone difficult to treat.
  • 25. Clinical Features  Mandible >Maxilla  Temporal bone also affected.  Time period- 7.5 years-20 years  Extra and intra oral fistula  Parasthesia and anaesthesia  Pathological fracture
  • 26.  TYPES: Early, trauma induced Spontaneous, without any trauma Late, trauma induced AREA OF EXPOSED MANDIBLE AFTER RADIOTHERAPY LOSS OF ORAL MUCOSA
  • 27. DESTRUCTION OF IRRADIATED BONE RESULTING FROM INFECTION
  • 28. TREATMENT  Debridement  Antibiotic- 2 million units  Supportive therapy  Analgesics- narcotic and non-narcotic drugs  Good oral hygiene  Bone resection.  Hyperbaric oxygen therapy
  • 30. MUSCULATURE  Inflammation and fibrosis of musculature due to radiation  Contracture and trismus of muscles of mastication  Masseter or pterygoid usually involved  Restriction in mouth opening starts about 2 months after completion of radiotherapy  Management : Physiotherapy may help in increasing opening distance
  • 31. REFERENCES  ORAL RADIOLOGY (PRINCIPLES AND INTERPRETATION) – WHITE & PHAROAH  ESSENTIALS OF ORAL AND MAXILLOFACIAL RADIOLOGY – FRENY R KARJODKAR