Dear Editor,
The article by Nath et al. (1) on the topic of dental care and treatment for patients with head and neck cancer (HNC) before, during, and after radiotherapy (RT) caught our attention and earned our respect (RT). The authors discussed the acute and chronic side effects of RT and chemoradiotherapy on HNC patients as well as the contributing factors. The authors also conducted a literature review on dental care, tooth extraction, decision-making criteria for tooth extraction, and precautions to be taken prior to, during, and following RT to prevent osteoradionecrosis (ORN) and rampant caries [1]. While the authors did a valuable job of outlining steps that can be taken to avoid these two complications, we do have two inquiries that need addressing.
First, the article reports that the prevalence of ORN is 5–15%, with variation depending on RT dose technique, total radiation dose, fractionation, tumor size and stage, age, and oral hygiene of the patients. Nevertheless, variations in primary tumor sites and tumor and/or nodal stages may modify the mean, maximum, and VX (jaw volume exposed to X Gray or higher) doses of RT received by the mandible, which are also among the established risk factors for the development of ORN [2]. In other words, total RT doses greater than 60 Gy pose a significant risk for ORN, but the total dose prescribed may not always be the exact dose to which the jaw is exposed. According to a study that examined the records of 402 oropharyngeal cancer patients [3], the ORN was more prevalent when the average dosage was > 66 Gy (range: 57–73 Gy) in the ORN region. V50 was also suggested as the dosimetric parameter to effectively reduce the incidence of ORN, emphasizing the significance of the mandibular VX as a better predictor of ORN than mean mandibular or tumor doses. Similarly, DeLuke et al. [4] reported that the dosage variables V50 Gy (cc) and V65 Gy (cc) exhibited greater predictability of ORN formation than the planned total dose. These findings demonstrate that placing too much weight on total tumor dose alone as an indicator of the genuine risk factors of ORN may be misleading.
Second, Nath et al. [1] identified pre-RT tooth extraction as a significant risk factor for ORN development; however, the increasing significance of the pre-RT traumatic load, measured by the number of extracted teeth, was not addressed. Nevertheless, Yilmaz et al. have recently highlighted a clear association between the number of teeth extracted before the C-CRT and the risk of ORN following C-CRT [5]. Patients with ≥ 4 extractions had a significantly higher risk of ORN than those with < 4 extractions (15.0–2.3%; P = 0.005), emphasizing the essence of preserving repairable teeth as far as is attainable. For these reasons, we believe that taking these factors into account among the causes of ORN, re-evaluating data, and providing information can yield valuable insights into the conclusive decisiveness of ORN risk factors and risk classification in HNC patients.
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References
- 1.Nath J, Singh PK, Sarma G (2022) Dental Care in Head and Neck Cancer Patients Undergoing Radiotherapy. Indian J Otolaryngol Head Neck Surg 74(Suppl 3):6219–6224. [DOI] [PMC free article] [PubMed]
- 2.Taylor JM, Mendenhall WM, Lavey RS (1992) Dose, time, and fraction size issues for late effects in head and neck cancers.Int J Radiat Oncol Biol Phys 22(1):3–11. [DOI] [PubMed]
- 3.Tsai CJ, Hofstede TM, Sturgis EM, Garden AS, Lindberg ME, Wei Q et al (2013) Osteoradionecrosis and radiation dose to the mandible in patients with oropharyngeal cancer. Int J Radiat Oncol Biol Phys 85(2):415–420. [DOI] [PubMed]
- 4.DeLuke D, Carrico C, Ray C, Stilianoudakis S, Holler S, Padilla L et al (2022) Is dose volume a better predictor of osteoradionecrosis risk than total dose for patients who have received head and neck radiation? J Oral Maxillofac Surg 80(9):1557–1563. [DOI] [PubMed]
- 5.Yilmaz B, Somay E, Selek U, Topkan E (2021) Pretreatment systemic immune-inflammation index predict needs for teeth extractions for locally advanced head and neck cancer patients undergoing concurrent chemoradiotherapy. Ther Clin Risk Manag 17:1113–1121. [DOI] [PMC free article] [PubMed]