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Cancer treatment, including radiation and chemotherapy, both affect the healing mechanism of the body and make it susceptible to minor injury. This is why even simple procedures like extractions must be carried out with a lot of caution.

Oral care during cancer treatment is very important and can lead to a number of serious complications. Patients must be educated about the increased risk of developing widespread tooth decay, gum disease, painful ulcers, dryness of the mouth and other such symptoms [1].

The idea of providing adequate dental care before and during cancer treatment is to minimize these complications as well as the need for any invasive procedures because they end up causing a lot more complications in turn [2].

Extractions in Cancer Patients

Ideally, every single cancer patient that is about to undergo radiotherapy targeted at the head and neck region would undergo a pre-treatment oral evaluation. This would allow the dentist to take aggressive measures and treat any areas of infection that exist right now or extract those teeth that may be a problem later on.

Unlike conventional treatment where the onus is on trying to save as many teeth as possible, the doctor here is going to err on the side of aggression and assume that any small infection now will go on to become a big problem once the cancer treatment begins [3].

The reason for this aggression in treatment planning is because doctors want to avoid any sort of bone trauma after the jawbone has been irradiated. Doctors should also educate the patients about the dental treatment required before cancer treatment behind so that such complications can be avoided.

Osteoradionecrosis

This term can be broken down into three parts which explain exactly what it means:

  • Osteo means bone,
  • radio as in radiation therapy
  • and necrosis means cell death.

Osteoradionecrosis refers to a condition where the cells of the bone undergo cell death since they are unable to respond like they normally would to trauma to the bone. Just for understanding, in normal bone, an extraction socket begins heals in around a week to 10 days for most people, while in the case of osteoradionecrosis that healing never occurs and in fact causes much more destruction of the surrounding structures instead [4].

Why Does Osteoradionecrosis Occur In Cancer Patients?

A number of studies have been conducted (and continue to be conducted) on the incidence of osteoradionecrosis which have found that the main causes behind its occurrence are radiation, trauma and a lack of oxygen to the cells [5].

Previous beliefs that microbial infection, the immune response of the body, chemotherapy and other factors caused osteoradionecrosis were found to have a minor role in its occurrence.

Once a bone has received a sufficient amount of radiation, it destroys the number of small blood vessels inside the bone. These blood vessels are responsible for carrying the cells that help the body remove the damaged cells and replace them with new ones, as happens in the case of a normal healing extraction socket [6].

In cancer patients, this lack of blood vessels means that not only is the body not able to respond adequately to this small insults but is also more susceptible to them.

How Are Extractions Done In Cancer Patients?

Unfortunately, a lack of knowledge in both patients and oncologists (Here is everything you need to know about preventing dental problems after cancer treatment) often leads to a situation where cancer patients end up needing extensive treatment after their radiation sessions have been completed. Some of the infected teeth will need to be removed because there is just no other option.

Care must be taken in such cases that extractions are the last choice of treatment and only carried out in a hospital setting [7].

Ideally, the patient would have undergone hyperbaric oxygen therapy before the extractions as well as a few dives into the chamber after the procedure has been completed.

There is evidence to show that treatment with hyperbaric oxygen is the best way to prevent and even treat osteoradionecrosis. The idea behind this treatment is quite straightforward. An increase in the concentration of oxygen is used to try and make sure the tissues have an adequate supply of oxygen and do not die because of a lack of it.

Hyperbaric oxygen also helps in the regeneration of small blood vessels in the bone that help in improving the amount of remodeling and repair that can take place after the extraction.

For high-risk patients that need extraction, treatment with hyperbaric oxygen is a must [8,9].

Is There A Time Frame After Which Extractions Can Be Performed Normally In Cancer Patients?

Yes, although, this time frame may vary from person to person. The fact is that it is next to impossible to give an exact time frame in a situation like this where so many variables are involved but as a rule of thumb, doctors should try to avoid extraction at all costs for the first 6-12 months after radiation has been completed or carry them out using hyperbaric oxygen therapy [10].

Extractions must also be carried out with a minimal amount of trauma and with proper antibiotic coverage to ensure that the healing takes place as uneventfully as possible.  

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