Case #3

By: Thanh Truong, DDS

A 65-year-old Caucasian female presented to the University of Oklahoma Advanced Education in General Dentistry in September 2020 as an external referral from the Stephenson Cancer Center for an evaluation for comprehensive dental care. Medical history includes a cancer history of radiation and chemotherapy, bifrontal craniotomy and lateral rhinotomy to remove an olfactory neuroblastoma with removal of retropharyngeal node metastases. The patient’s last round of radiation therapy was in 2010, with the maxillary left posterior area receiving more than 55 Gy, and the mandible also received more than 55 Gy. The patient’s last round of chemotherapy (IV Cisplatin) was in 2019. The patient’s current medications included Sudafed, Aleve, and Clinpro 5000ppm fluoride toothpaste. The patient had multiple decayed teeth due to severe xerostomia (see Figure 1&2). The patient’s chief complaint was “I just want my teeth to be taken care of. I don’t want to keep losing my teeth.” The patient also stated that she had been unable to find a dentist to treat her due to her medical history for ten years.

After thorough discussion with all treating parties, the proposed treatment plan included extracting #2, 3, 4, 9, 10, 13, 18, 30, 31 due to non-restorability. The extraction would be done by the OU Oral Surgery Department, with a plan to remove only one tooth at a time to reduce soft tissue trauma. Therefore, any development of osteoradionecrosis might possibly be manageably taken care of. While these teeth are awaiting extraction, they will receive silver diamine fluoride to stop decay progression. Restorative treatments included composite fillings on #5-B, 7-MDL, 8-ML, 29-MO, and a maxillary immediate partial denture to replace #4, 9, 10, and 13. The patient will have adequate function with a shortened dental arch (up to 2nd premolars).

As of April of 2023, the patient had #2, 13, 18, 30, and 31 extracted, fillings on #5-B, 7-MDL, 8-ML, 29-MO, and SDF application on #9-D and 10-M. The patient had excellent soft tissue healing and bone healing without any sign of osteoradionecrosis (see Figure 2). Ongoing treatment includes extraction of #3 and 4. Immediate delivery of maxillary immediate partial denture will follow extraction of #9 and 10.

It should be noted that the clinician’s efforts for the patients while they are undergoing radiation therapy should be focused on managing side-effects from treatment such as mucositis and dry mouth as well as educating patients about the importance of routine dental hygiene procedures to maintain a healthy dentition. After patients’ complete radiation therapy, the clinician’s priority shifts to minimizing soft and hard tissue trauma, as it could lead to osteoradionecrosis (ORN). ORN occurs in approximately 9% of patients who receive more than 70 Gy of ionizing radiation to treat head and neck malignancy, 2% of patients who receive 60 – 70 Gy, and almost 0% in patients who receive less than 60 Gy. Furthermore, the mandible is 7 times more likely to develop ORN than the maxilla due to mandibular bone being denser and less vascular. Non-surgical procedures are safe and are recommended to avoid tooth loss which may include scaling and root planing, non-surgical endodontic treatments, and all restorative procedures. Removable appliances can cause ORN from tissue trauma and may need to be adjusted frequently.

Besides reducing tissue trauma, other methods can be used to reduce the chance of patients developing ORN. Hyperbaric oxygen (HBO) therapy is recommended before and after surgery. These patients typically receive 20 pre-extraction HBO sessions followed by 10 post-extraction sessions. Other considerations include use of local anesthetics without vasoconstrictor, and prophylactic antibiotics for dental procedures. Interestingly, a shortened dental arch (with all teeth up to 2nd premolars) has been shown to provide enough function for most patients.

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ABOUT THE AUTHOR

Dr. Thanh Truong was born and raised in Vietnam, and now considers himself an Okie native. He graduated summa cum laude from the University of Oklahoma with a B.S. degree in Biochemistry and a minor in Mathematics. After receiving his D.D.S. degree with distinction from the University of Oklahoma College of Dentistry, he attended the dental school’s AEGD residency program to receive advanced training in comprehensive care. Dr. Truong looks forward to growing his family and beginning his career in Oklahoma City.