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Oral complications of head and neck radiotherapy: the importance of the dental surgeon

Complicações orais da radioterapia de cabeça e pescoço: a importância do cirurgião-dentista

ABSTRACT

Objective:

radiotherapy can lead to different adverse effects in the oral epithelial cells. This article aimed to address the main oral manifestations associated with radiotherapy of head and neck neoplasms, highlighting the importance of the dental practitioners’ participation within the skilled multidisciplinary personnel to treatment.

Methods:

Research was conducted in the PubMed, Lilacs, SciELO, and Google Scholar databases using the keywords “head and neck radiotherapy”, “oral manifestations’’, and “head and neck neoplasm”. Eighteen out of 533 articles published between 2015 and 2022 were selected after duplicates removal and eligibility criteria application.

Results:

xerostomia, hyposalivation, trismus, dysgeusia, dysphagia, dentin hypersensitivity, fungal and viral infections, radiation caries, osteoradionecrosis, mucositis, periodontal alterations, and tooth development abnormalities were the most frequently reported oral effects of radiotherapy.

Conclusions:

The participation of dentists in the multidisciplinary team that treats patients with head and neck cancers is fundamental since several oral complications of radiotherapy are observed. Dentists can prevent, reduce and treat some detrimental effects whether the patient is followed-up since the beginning of radiotherapy.

Indexing terms
Head and neck neoplasm; Oral manifestations; Radiotherapy

RESUMO

Objetivo:

A radioterapia pode levar a diferentes efeitos adversos nas células epiteliais orais. Este artigo teve como objetivo abordar as principais manifestações bucais associadas à radioterapia de neoplasias de cabeça e pescoço, destacando a importância da participação do cirurgião-dentista na equipe multidisciplinar apta ao tratamento.

Métodos:

foi realizada uma busca nas bases de dados PubMed, Lilacs, SciELO e Google Acadêmico utilizando as palavras-chave “radioterapia cabeça e pescoço”, “manifestações orais” e “neoplasma de cabeça e pescoço”. Dezoito dos 533 artigos publicados entre 2015 e 2022 foram selecionados após a remoção das duplicatas e aplicação dos critérios de elegibilidade.

Resultado:

xerostomia, hipossalivação, trismo, disgeusia, disfagia, hipersensibilidade dentinária, infecções fúngicas e virais, cárie de radiação, osteorradionecrose, mucosite, alterações periodontais, e anormalidades do desenvolvimento dentário foram os efeitos orais da radioterapia mais relatados.

Conclusão:

A participação dos dentistas na equipe multidisciplinar que atende pacientes com câncer de cabeça e pescoço é fundamental, pois são observadas diversas complicações bucais da radioterapia. Os dentistas podem prevenir, reduzir e tratar alguns efeitos deletérios se o paciente for acompanhado desde o início da radioterapia.

Termos de Indexação
Neoplasias de cabeça e pescoço; Manifestações bucais; Radioterapia

INTRODUCTION

Cancer is an abnormal proliferation of malignant neoplastic cells during mitosis, and it is commonly determined by environmental factors such as solar radiation, alcohol, and tobacco consumption [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...

2 Ferreira RMOSV, Campos MS, Darze D, Meira R. Oral manifestations associated with radiotherapy: literatura review. Rev Ciênc Atual. 2021;17(1):110-117.
-33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.]. The National Cancer Institute reports malignant neoplasms as the third cause of death in Brazil (fifth and thirteenth cause in men and women, respectively) [44 Brazil. Ministério da Saúde. Relatório sobre o cenário assistencial e epidemiológico do câncer de lábio e cavidade oral no Brasil. Inca. 2020;2(1):1-27.]. Lips, gingiva, hard palate, tongue, and mouth floor present the highest occurrence of oral cancer.

Radiotherapy, chemotherapy, and surgery have been the most effective treatments used for head and neck cancers [22 Ferreira RMOSV, Campos MS, Darze D, Meira R. Oral manifestations associated with radiotherapy: literatura review. Rev Ciênc Atual. 2021;17(1):110-117.]. Variations in some factors such as radiation technique, total dose, fractionation, and device type may lead to different adverse effects in the oral epithelial cells of patients who have been submitted to head and neck radiotherapy [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.]. Xerostomia, hyposalivation, trismus, dysgeusia, dysphagia, dentin hypersensitivity, fungal and bacterial infections, radiation caries, osteoradionecrosis, mucositis, periodontal alterations, and tooth development abnormalities are the most frequently reported oral manifestations associated with head and neck radiotherapy [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.,55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
,66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
]. This article aimed at addressing the main oral manifestations associated with radiotherapy of both head and neck neoplasms.

METHODS

Research was conducted in the PubMed, Lilacs, SciELO, and Google Scholar databases using keywords such as “head and neck radiotherapy”, “oral manifestations’’, and “head and neck neoplasm”. Eighteen out of 533 articles published between 2015 and 2022 were selected after duplicates removal and eligibility criteria application, as it can be observed in figure 1. The inclusion criteria established were publication on the proposed article’s theme of the last eight years; scientific articles written in English and Portuguese languages and institutional site of extreme relevance to the subject in question. The exclusion criteria used were articles that did not address to the subject in a clear way. During the research, 14 scientific articles were consulted and selected, 3 of them were outside the selection curve because they were published before the period established previously, however, these were chosen due to their content relevance for familiarizing with the theme, as well as for their development, for this reason they have been incorporated in this review. In addition, 1 institutional site was consulted and incorporated in this article: National Cancer Institute (INCA). Therefore, totaling 18 surveys included in this study, 5 in English and 13 in Portuguese language.

Figure 1
Flowchart of the study.

RESULTS

Radiotherapy combined, or not, with surgery and/or chemotherapy in order to treat head and neck cancers is possible [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,22 Ferreira RMOSV, Campos MS, Darze D, Meira R. Oral manifestations associated with radiotherapy: literatura review. Rev Ciênc Atual. 2021;17(1):110-117.]. Aforementioned, this therapy uses corpuscular or electromagnetic ionizing radiation that inhibits or undermines tumor cells [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
]; however, this non-selective radiation may harm healthy cells and lead to systemic and oral detrimental effects [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
]. Damage to salivary glands and mucositis have already been observed among patients who have received doses between 20 - 30 Gy [88 Fernandes AS, Oliveira BCL, Silva LMC, Ohse DH, Pimenta YS. Dental care for patients undergoing head and neck radiotherapy: literature review. Electr J Collect Health. 2021;13(1):1-7.,99 Kawashita Y, Soutome S, Umeda M, Saito, T. Oral management strategies for radiotheapy of head and neck câncer. Jpn Dent Sci Rev. 2020;56(1):62-67. http://dx.doi.org/10.1016/j.jdsr.2020.02.001
https://doi.org/10.1016/j.jdsr.2020.02.0...
]. Head and neck radiotherapy may lead to both intense and tardily oral manifestations. Commonly observed, mucositis appears to be the most frequent acute effect after seven days [of treatment] [66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
,99 Kawashita Y, Soutome S, Umeda M, Saito, T. Oral management strategies for radiotheapy of head and neck câncer. Jpn Dent Sci Rev. 2020;56(1):62-67. http://dx.doi.org/10.1016/j.jdsr.2020.02.001
https://doi.org/10.1016/j.jdsr.2020.02.0...
]; in spite of, its intensity, duration, and chronology have been related to irradiation parameters and/or the cytotoxicity of drugs (in cases of combined chemotherapy) [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,99 Kawashita Y, Soutome S, Umeda M, Saito, T. Oral management strategies for radiotheapy of head and neck câncer. Jpn Dent Sci Rev. 2020;56(1):62-67. http://dx.doi.org/10.1016/j.jdsr.2020.02.001
https://doi.org/10.1016/j.jdsr.2020.02.0...
]. The irradiation causes cell death, inhibits the tissue recovery, and totally or partially exposes the oral mucosa [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
]; in addition, multiple ulcerated fibrinous lesions covered by pseudomembranes, erythema, edema, pain, dysphagia, and nutrition deficiency might be observed [55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
].

Moreover, exposure to radiation doses between 40 to 65 Gy drives to inflammation and consequently atrophy of salivary glands. Therefore, reduction of salivary flow may result in xerostomia (dry mouth sensation), labial commissures fissures, lip dryness, and dysgeusia (taste alteration) [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.,66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
]. Furthermore, radiation caries (secondary caries) may occur from three weeks up to one year [22 Ferreira RMOSV, Campos MS, Darze D, Meira R. Oral manifestations associated with radiotherapy: literatura review. Rev Ciênc Atual. 2021;17(1):110-117.]. The patient may lose appetite and present psychological disorders [66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
].

Periodontal alterations may be observed in patients who have been submitted to head and neck radiotherapy subordinated to the radiation dose [55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
]. The periodontal ligament is a non-mineralized tissue that connects the cementum and alveolar bone; however, it is fragile and susceptible to morpho-histological changes induced by radiotherapy that may result in tissue destruction, premature tooth loss, and bone infections. Additionally, ionizing radiations higher than 60 Gy may result in a late and certanly severe complication known as osteoradionecrosis, which occurs more often in the lower jaw due to its high bone density and its reduced vascularization [55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
,1010 Santos, Paulo SS, Cremonesi AL, Quispe RA, Rubira CMF. The impact of oral health on quality of life in individuals with head and neck cancer after radiotherapy: the importance of dentistry in psychosocial issues. Acta Odontol Latinoam. 2017;30(2):62-67.]. The osteoradionecrosis is characterized by bone ischemia and surrounding tissues that reduces the number of osteocytes and osteoblasts; thus, bone healing and remodeling can be jeopardized, and the affected site becomes necrotic [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.,55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
]. Soft tissues edema and erythema, exposure of necrotic bone, trismus, ulcers, lymphadenopathy, suppuration, pain, paresthesia, pathological fracture, fistula, mobility, periapical and periodontal pathologies are signs and symptoms that indicate osteoradionecrosis [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.,55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
]. Poor oral hygiene, alcohol, and tobacco excessively, tooth extractions after radiotherapy, previous bone surgeries, bone inflammation, and systemic diseases can be risk factors for osteoradionecrosis [55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
].

Trismus is a late manifestation that frequently occurs three to six weeks after the completion of radiotherapy. The limited mouth opening impairs eating and oral cleaning [1111 Borges BS, Vale DA, Aoki R, Trivino T, Fernandes KS. Atendi-mento odontológico de paciente submetido à radioterapia em região de cabeça pescoço: relato de caso clínico. Rev Odontol UnivCid. 2018;30(3):332-340.]. This condition is often related to malignant lesions in the soft palate and retromolar region since the exposure of the temporomandibular joint and masticatory muscles to radiation result in muscular fibrosis and reduced vascularization [66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
, 1111 Borges BS, Vale DA, Aoki R, Trivino T, Fernandes KS. Atendi-mento odontológico de paciente submetido à radioterapia em região de cabeça pescoço: relato de caso clínico. Rev Odontol UnivCid. 2018;30(3):332-340.].

Considering deciduous teeth are sensitive to morphological and structural changes, pediatric patients and pregnant women submitted to head and neck radiotherapy may show abnormalities such as root deformation, dwarfism, or dilaceration, incomplete tooth calcification, premature root canal closure, microdontia, and hypodontia [66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
,1212 Lima IH, Andrade CES, Silva IVS, Vasconcelos MG, Vasconcelos RG. The main changes of dental development. Salusvita. 2017;36(2):533-563.].

Head and neck radiotherapy can also induce fungal and viral infections due to depression of the patient’s immune system that does not fight against opportunistic oral microorganisms effectively [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1313 Gabe C, Almeida DR, Siqueira LO. Evaluation of opportunistic infections in children suffering from leukemia. Rev Bras Hematol Hemoter. 2009;31(2):74-79. http://dx.doi.org/10.1590/S1516-84842009005000017
https://doi.org/10.1590/S1516-8484200900...
,1414 Sena MF, Gondim LAM, Souza GCA, Ferreira MAF, Lima KC. Treatment of oral candidiasis in patients with head and neck cancer: a systematic review. Rev AMRIGS. 2009:53(3):241-245.]. Candidiasis is the most prevalent fungal infection, which is associated to salivary reduction flow and poor oral hygiene [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1111 Borges BS, Vale DA, Aoki R, Trivino T, Fernandes KS. Atendi-mento odontológico de paciente submetido à radioterapia em região de cabeça pescoço: relato de caso clínico. Rev Odontol UnivCid. 2018;30(3):332-340.,1414 Sena MF, Gondim LAM, Souza GCA, Ferreira MAF, Lima KC. Treatment of oral candidiasis in patients with head and neck cancer: a systematic review. Rev AMRIGS. 2009:53(3):241-245.]. The proliferation of the Candida Albicans fungus forms white pseudomembranous or erythematous plaques (“cottage cheese” appearance) that can be removed by scraping [technique] [1111 Borges BS, Vale DA, Aoki R, Trivino T, Fernandes KS. Atendi-mento odontológico de paciente submetido à radioterapia em região de cabeça pescoço: relato de caso clínico. Rev Odontol UnivCid. 2018;30(3):332-340.].

Herpes simplex virus and zoster are more likely to affect the oral cavity and lead to the occurrence of grouped erythematous and ulcerated lesions in the palate, labial commissure, and nose base, and systemic manifestations such as lymphadenopathy and fever [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55., 88 Fernandes AS, Oliveira BCL, Silva LMC, Ohse DH, Pimenta YS. Dental care for patients undergoing head and neck radiotherapy: literature review. Electr J Collect Health. 2021;13(1):1-7.].

Oral manifestations previously mentioned can be treated, controlled, or even prevented by the addition of the dental surgeon to the multidisciplinary oncology personnel, as this professional caries enough knowledge, not only about the common oral manifestations that affect the ionized patient, but also about the care service protocol and the resources that can be used to improve the patient’s quality of life [1111 Borges BS, Vale DA, Aoki R, Trivino T, Fernandes KS. Atendi-mento odontológico de paciente submetido à radioterapia em região de cabeça pescoço: relato de caso clínico. Rev Odontol UnivCid. 2018;30(3):332-340.,1515 Fernandes IS, Fraga CPT. The importance of dentist surgery in adverse effects in the oral cavity of oncological treatment of head and neck. Rev Cient UMC. 2018;4(1):1-16.].

The dentist’s performance is based upon the elimination of the infectious, inflammatory focus and pain episode [1616 Lima LCS, Andalécio MM, Andrade RS, Machado FC, Novais VR, Carvalho TA. Oral clinical implications and the importance of dental care in palliative care patients: an integrative literature review. 2021;10(9):1-8. http://dx.doi.org/10.33448/rsd-v10i9.18356
https://doi.org/10.33448/rsd-v10i9.18356...
]. Therefore, it is important that the oncological patients begin dental treatment before radiotherapy to be given oral hygiene instruction and non-traumatic dental extractions which may prevent the development of osteoradionecrosis [66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
, 77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
].

During the cancer treatment as issued, the dental surgeon may offer treatment for mucositis by prescribing amifostine or laser therapy sessions for pain relief. In addition to treating candidiasis by antimicrobials, such as chlorhexidine and nystatin mouthwash [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1616 Lima LCS, Andalécio MM, Andrade RS, Machado FC, Novais VR, Carvalho TA. Oral clinical implications and the importance of dental care in palliative care patients: an integrative literature review. 2021;10(9):1-8. http://dx.doi.org/10.33448/rsd-v10i9.18356
https://doi.org/10.33448/rsd-v10i9.18356...
]. Subsequently antineoplastic therapy, the dental surgeon remains essential concerning the patient’s health, since he controls, treats, or even prevents the beginning of persistent and/or late oral manifestations, enabling quality of life by reducing or remedying symptoms caused by radiation therapy complications [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
].

The content previously approached has been verified from the reading of the articles that supported this study, and can be summarized as follows in table 1, which presents the authors, the type of study carried out by them, the objectives of their research and the conclusions conferred.

Table 1
Characteristics of researched studies.

DISCUSSION

Oral cancer represents a therapeutic challenge. This pathology can be treated by surgical modality, chemotherapy or radiotherapy, these methods can be combined or performed in isolated procedures [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,22 Ferreira RMOSV, Campos MS, Darze D, Meira R. Oral manifestations associated with radiotherapy: literatura review. Rev Ciênc Atual. 2021;17(1):110-117.].

Radiotherapy is one of the most applicable therapeutic methods for the treatment of oral cancer, especially to treat initial lesions, it has had good results and indications [1818 Silva JKMC, Rios TLB, Guedes CCFV. Dental care for patients undergoing antineoplasic treatments. Res Soc Develop. 2021;10(12);e99101220231. http://dx.doi.org/10.33448/rsd-v10i12.20231 //
https://doi.org/10.33448/rsd-v10i12.2023...
]. Such therapy is based on the application of corpuscular or electromagnetic ionizing radiation at a specific local to inhibit or destroy neoplastic cells in the body [11 Conceição TC, Sanches ACB, Freire TFC, Martins GB, Marques MVC, Dantas JBL. Acute oral manifestations in patients submitted to radiotherapy in the head and neck region: literature narrative review. J Health Sci. 2021;23(1):92-98. http://dx.doi.org/10.17921/2447-8938.2021v23n2p92-98
https://doi.org/10.17921/2447-8938.2021v...
,77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
].

Nevertheless, as radiation is not selective, there are aggressiveness towards healthy cells of the human organism, allowing manifestation of signs and systemic symptoms, and oral. The side effects of this specific modality issued are dose-dependent, that is, they are manifested from the administration of a certain dose in the head and neck region, such as, for example, 20-30 Gy, damaging the salivary glands and causing the presence of mucositis in the oral cavity [88 Fernandes AS, Oliveira BCL, Silva LMC, Ohse DH, Pimenta YS. Dental care for patients undergoing head and neck radiotherapy: literature review. Electr J Collect Health. 2021;13(1):1-7.,99 Kawashita Y, Soutome S, Umeda M, Saito, T. Oral management strategies for radiotheapy of head and neck câncer. Jpn Dent Sci Rev. 2020;56(1):62-67. http://dx.doi.org/10.1016/j.jdsr.2020.02.001
https://doi.org/10.1016/j.jdsr.2020.02.0...
].

Encompassed by the oral manifestations, emerging from the main side effects of head and neck radiotherapy, it is observed: xerostomia, hyposalivation, trismus, dysgeusia, dysphagia, dentin hypersensitivity, fungal and viral infections, radiation caries, osteoradionecrosis, mucositis, periodontal changes, and abnormalities in the structural development of teeth [33 Paiva MDEB, Biase RCCG, Moraes JJC, Ângelo AR, Honorato MCTM. Oral complications of cancer therapy. Arq Odontol. 2016;46(1):48-55.,55 Sroussi HY, Epstein JB, Bensadoun RJ, Saunders DP, Lalla RV, Migliorati CA, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva, chage, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017;6(12):2918-2931. http://dx.doi.org/10.1002/cam4.1221
https://doi.org/10.1002/cam4.1221...
,66 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J. 2015;218(2):65-68. http://dx.doi.org/10.1038/sj.bdj.2015.28
https://doi.org/10.1038/sj.bdj.2015.28...
].

Oral complications such as these, resulting from radiotherapy can be treated, controlled and/or prevented through dental care service provided to the oncology personnel by the dental surgeon. This professional performs pre-, trans-, and post-radiation therapy treatments in order to assist preparation of the oral cavity to receive radiation, in addition, such expert treat and relieve signs and symptoms, respectively [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1515 Fernandes IS, Fraga CPT. The importance of dentist surgery in adverse effects in the oral cavity of oncological treatment of head and neck. Rev Cient UMC. 2018;4(1):1-16.].

The professional quoted promotes guidance on the use of medication, takes actions to minimize painful symptoms in the patient to restore function and quality of life [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1515 Fernandes IS, Fraga CPT. The importance of dentist surgery in adverse effects in the oral cavity of oncological treatment of head and neck. Rev Cient UMC. 2018;4(1):1-16.

16 Lima LCS, Andalécio MM, Andrade RS, Machado FC, Novais VR, Carvalho TA. Oral clinical implications and the importance of dental care in palliative care patients: an integrative literature review. 2021;10(9):1-8. http://dx.doi.org/10.33448/rsd-v10i9.18356
https://doi.org/10.33448/rsd-v10i9.18356...

17 Rapoport A, Kowalski LP, Herter NT, Brandão LG, Walder F. Rastreamento, diagnóstico e tratamento do câncer de boca. Projeto Diretrizes – Associação Médica Brasileira e Conselho Federal de Medicina. São Paulo: Sociedade Brasileira de Cirurgia de Cabeça e Pescoço; 2001. Disponível em: <https://amb.org.br/files/_BibliotecaAntiga/rastreamento-diagnostico-e-tratamento-do-cancer-de-boca.pdf>.
https://amb.org.br/files/_BibliotecaAnti...
-1818 Silva JKMC, Rios TLB, Guedes CCFV. Dental care for patients undergoing antineoplasic treatments. Res Soc Develop. 2021;10(12);e99101220231. http://dx.doi.org/10.33448/rsd-v10i12.20231 //
https://doi.org/10.33448/rsd-v10i12.2023...
]. Among these issues, it is possible to mention the prescription of mouthwash and laser therapy in the region of pain [77 Sen S, Priyadarshini SR, Sahoo PK, Dutta A, Kumar U. Palliative oral care in patients undergoing radiotherapy: Integrated review. J Family Med Prim Care. 2020;9(10):5127-5131. http://dx.doi.org/10.4103/jfmpc.jfmpc_827_20
https://doi.org/10.4103/jfmpc.jfmpc_827_...
,1515 Fernandes IS, Fraga CPT. The importance of dentist surgery in adverse effects in the oral cavity of oncological treatment of head and neck. Rev Cient UMC. 2018;4(1):1-16.,1717 Rapoport A, Kowalski LP, Herter NT, Brandão LG, Walder F. Rastreamento, diagnóstico e tratamento do câncer de boca. Projeto Diretrizes – Associação Médica Brasileira e Conselho Federal de Medicina. São Paulo: Sociedade Brasileira de Cirurgia de Cabeça e Pescoço; 2001. Disponível em: <https://amb.org.br/files/_BibliotecaAntiga/rastreamento-diagnostico-e-tratamento-do-cancer-de-boca.pdf>.
https://amb.org.br/files/_BibliotecaAnti...
].

CONCLUSION

The participation of dental surgeons in the multidisciplinary personnel that treats patients with head and neck cancers is fundamental since several oral complications of radiotherapy have been observed. Dentists can prevent, reduce, and treat some detrimental effects whether the patient has been accompanied since the beginning of radiotherapy.

How to cite this article

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Edited by

Assistant editor: Luciana Butini Oliveira

Publication Dates

  • Publication in this collection
    09 Oct 2023
  • Date of issue
    2023

History

  • Received
    24 June 2022
  • Reviewed
    26 Feb 2023
  • Accepted
    10 Mar 2023
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