**5. Protocol for management After RTP**

Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine months, 12 months and 18 months. From then onwards, patients are reviewed semi-annually. A new OPG requested 12 months after ending RTP.

In each of the reviews, the oral condition of the patient is assessed to establish treatment needs, developing the following examinations that are covered in the protocol.

#### **5.1. RTP protocol**


Grade 0: Absence of dental plaque.

Little can be done to improve the toxicity of the skin, aside from moisturizing several times a day and not covering the area so it does not keep moisture. We also recommend leaving it to

Patients usually experience weight loss due to difficulties in swallowing caused by mucositis. Taste alterciones causes a loss of appetite and dietary recommendations are necessary.

Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine months, 12 months and 18 months. From then onwards, patients are reviewed

In each of the reviews, the oral condition of the patient is assessed to establish treatment needs,

**1.** Odontogram with the current situation after undergoing RTP, dental and periodontal

air dry.

**Management During RTP**

186 Updates on Cancer Treatment

2. Treatment of complications. 3. Instructions of oral hygiene.

8. Exercise to reduce trismus.

**5.1. RTP protocol**

status.

4. Liquid or soft diet. 5. Avoid extractions. 6. Remove toxic habits.

a) Degree of mucositis. b) Degree of radiodermatitis. c) Degree of oral hygiene. d) Presence of ORN.

1. Revisions, once a week, during treatment with radiotherapy valued:

e) Eliminate possible graze, if the patient has removable/complete prosthesis.

i) Maximum interincisal distance at mid-treatment and at the end.

f) Dental state and instructions in oral hygiene. g) Saliva amount by means of TSG I and TSG II. h) Culture at mid-treatment and at the end.

7. Remove any mechanical trauma to the oral mucosa.

**5. Protocol for management After RTP**

**2.** Rating of oral hygiene: the Silnesloe index [49]

semi-annually. A new OPG requested 12 months after ending RTP.

developing the following examinations that are covered in the protocol.

Grade 1: Plaque not visible but can be extracted from the gingival third of the tooth using the probe.

Grade 2: Moderate build-up of plaque in the gingival region that can easily be seen.

Grade 3: Abundance of plaque in the same region, possibly covering the neighbouring teeth.


#### **Patient attending the annual review after finishing the RTP. We see good oral and dental hygiene and healthy appearance of mucous.**

Follows the same pattern (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).

#### **Patient who comes to review after 14 months of finishing RTP. He has lost four lower incisive and the root-canal therapy we sent to keep them up to remove them.**

The first Figure 39 shows the patient's condition before the RTP. Siguentes figures show the patient's current state (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).

10. Radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and

11 Motivation in oral hygienic - strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation plan in patients with teeth - preparation of individual trays for the daily application of

**Patient attending the annual review after finishing the RTP. We see good oral and dental hygiene and healthy** 

intraoral (maxima intercuspidation, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue).

sodium fluoride gel at 1.24%, five minutes/day, indefinitely and wash mouth with clorhexidine.

intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).

Figure 39: Before RTP **Figure 39.** Before RTP

Figure 39: Before RTP

can see the various statuses of rampant caries and poor oral hygiene, except in a case where there is excellent oral hygiene The figures below show the oral health status of different patients after one year of finishing the RTP. Here, you can see the various statuses of rampant caries and poor oral hygiene, except in a case where there is excellent oral hygiene **The figures below show the oral health status of different patients after one year of finishing the RTP. Here, you can see the various statuses of rampant caries and poor oral hygiene, except in a case where there is excellent oral hygiene**

Radiotherapy and Chemotherapy Treatments in Head and Neck Cancer Patients — Protocol for Management… http://dx.doi.org/10.5772/60397 189

#### **4.2 Assessment of Osteoradionecrosis 5.2. Assessment of osteoradionecrosis**

**1.** It is classified according to the grade of bone affectation [94, 95]. The time of apparition after RTP and the association to exodoncias are valued either pre or post RTP.

1. It is classified according to the grade of bone affectation (94, 95). The time of apparition after RTP and the association to exodoncias are valued either pre or post RTP. Stage I: Osteoradionecrosis superficial - soft-tissue ulceration is minimal and only the exposed cortical bone is necrotic.

Stage I: Osteoradionecrosis superficial - soft-tissue ulceration is minimal and only the exposed cortical bone is necrotic. Stage II: Osteoradionecrosis localized - the exposed cortical bone and underlying medullary bone are necrotic.

Stage II: Osteoradionecrosis localized - the exposed cortical bone and underlying medullary bone are necrotic. IIA: Soft-tissue ulceration is minimal.

IIA: Soft-tissue ulceration is minimal. IIB: Soft-tissue necrosis (including orocutaneous fistulation).

IIB: Soft-tissue necrosis (including orocutaneous fistulation). Stage III: Osteoradionecrosis diffuse - bone necrosis full thickness of a segment (ability to pathological fracture). Stage III: Osteoradionecrosis diffuse - bone necrosis full thickness of a segment (ability to pathological fracture).

IIIA: Soft-tissue ulceration is minimal.

IIIA: Soft-tissue ulceration is minimal. IIIB: Soft-tissue necrosis (including orocutaneous fistulation). IIIB: Soft-tissue necrosis (including orocutaneous fistulation).

**2.** Diagnosis

Patient who comes to review after 14 months of finishing RTP. He has lost four lower incisive and the root-canal

10. Radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and

11 Motivation in oral hygienic - strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation plan in patients with teeth - preparation of individual trays for the daily application of

**Patient attending the annual review after finishing the RTP. We see good oral and dental hygiene and healthy** 

Follows the same pattern (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral

intraoral (maxima intercuspidation, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue).

sodium fluoride gel at 1.24%, five minutes/day, indefinitely and wash mouth with clorhexidine.

intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).

The first Figure 39 shows the patient's condition before the RTP. Siguentes figures show the patient's current state (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right

Patient who comes to review after 14 months of finishing RTP. He has lost four lower incisive and the root-canal

The first Figure 39 shows the patient's condition before the RTP. Siguentes figures show the patient's current state (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right

The figures below show the oral health status of different patients after one year of finishing the RTP. Here, you can see the various statuses of rampant caries and poor oral hygiene, except in a case where there is excellent

The figures below show the oral health status of different patients after one year of finishing the RTP. Here, you can see the various statuses of rampant caries and poor oral hygiene, except in a case where there is excellent

**except in a case where there is excellent oral hygiene**

**The figures below show the oral health status of different patients after one year of finishing the RTP. Here, you can see the various statuses of rampant caries and poor oral hygiene,**

therapy we sent to keep them up to remove them.

therapy we sent to keep them up to remove them.

and left buccaal mucosa and tongue).

**appearance of mucous.** 

188 Updates on Cancer Treatment

and left buccaal mucosa and tongue).

Figure 39: Before RTP

Figure 39: Before RTP

**Figure 39.** Before RTP

oral hygiene

oral hygiene

2. Diagnosis It is based on the clinical findings and medical history of the patient with the confirmation of a radiology study and biopsy - exposed area of bone necrosis due to tissue-irradiation, minimum cure of three to six months, without evidence of local healing and neoplastic It is based on the clinical findings and medical history of the patient with the confirmation of a radiology study and biopsy - exposed area of bone necrosis due to tissue-irradiation, minimum cure of three to six months, without evidence of local healing and neoplastic absenceenfermdad [38, 41, 96].

absence enfermdad (38, 41, 96). The symptoms can manifest months or years after the radiation of the patient. The injuries appear as ulcerations, with the exposure of rough and necrotic bone. In some cases, the injuries are discovered during a visual inspection of the cavity or due to the incommodity in a determined part of the mouth. The symptoms can manifest months or years after the radiation of the patient. The injuries appear as ulcerations, with the exposure of rough and necrotic bone. In some cases, the injuries are discovered during a visual inspection of the cavity or due to the incommodity in a determined part of the mouth.

3. Treatment **3.** Treatment

In the first stage, a conservative treatment must be carried out. First, all irritants of the mouth are eliminated such as tobacco, alcohol and removable/complete prosthesis. Then, good oral hygiene and oral rinse with clorixidine 0,12 is carried out three times a day and a gel of clorhexidine is applied on the injuries three or four times a day.

In stage II, there is symptomatology and so the previous actions must be completed with an antibiotic treatment. In these cases, we can do a curettage of the exposed part until vital and vascular zone [97].

In stage III, pain can be intense and fistulization, suppuration and fractures can occur. Here, more radical surgery is needed to eliminate the osteolytic zone remaining vascularized [98].

#### **5.3. Extraction post-RTP**

The criteria established by Sulaiman et al. and Jansma et al. should be followed. After radiation therapy, it is necessary to delay any surgery for 18 months in order to reduce risks. The recommendations below should be followed [52, 53]:


#### **Management After RTP**

1. Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine

months, 12 months and 18 months. From then onwards, patients are reviewed semi-annually. A new OPG is requested 12 months after the end of the RTP.


c) Presence of ORN.


#### **Management After RTP**

f) Culture.

hygiene and oral rinse with clorixidine 0,12 is carried out three times a day and a gel of

In stage II, there is symptomatology and so the previous actions must be completed with an antibiotic treatment. In these cases, we can do a curettage of the exposed part until vital and

In stage III, pain can be intense and fistulization, suppuration and fractures can occur. Here, more radical surgery is needed to eliminate the osteolytic zone remaining vascularized [98].

The criteria established by Sulaiman et al. and Jansma et al. should be followed. After radiation therapy, it is necessary to delay any surgery for 18 months in order to reduce risks. The

**•** -Anaesthesia without vasoconstrictor - truncal block, infiltrative anaesthesia, never intrali‐

**•** Minimal trauma, alveolectomy, regularization of the alveolar process with no rotary

**•** Always prophylactic antibiotic (Amoxicillin 750mg 1/8 hours/10 days, if allergic to penicil‐ lin, a combination of spiramycin and metronidazole (Rhodogil®) is prescribed - two every

**•** Post-operative treatment: analgesic-anti-inflammatory medication (Ibuprofen 600mg) and

1. Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine months, 12 months and 18 months. From then onwards, patients are reviewed semi-annually. A new OPG is requested

antiseptic mouthwash chlorhexidine digluconate 0.12%, plus antibiotics.

**•** Rinse with antiseptic mouthwash - chlorhexidine digluconate 0.12%, one minute.

clorhexidine is applied on the injuries three or four times a day.

recommendations below should be followed [52, 53]:

**•** Primary sealing with mucoperiosteal flaps.

vascular zone [97].

190 Updates on Cancer Treatment

**5.3. Extraction post-RTP**

**•** Anaesthetic technique:

gamental anaesthesia.

**•** Non-absorbable 4.0 silk suture.

eight hours, for 10 days).

**•** Space the extractions in time.

12 months after the end of the RTP. a) Residual mucositis and radiodermatitis. b) Grade of oral hygiene - oral hygiene motivation.

e) Global Saliva Test (TSG), both at rest (TSG I) and stimulated (TSG II).

**Management After RTP**

c) Presence of ORN. d) Oral dental status.

instruments.

g) Maximum interincisal distance.

2. Avoid extractions at least 18 months after finishing the RTP.

3. Avoid performing or complete/removable prosthesis for three to six months post-RTP.

4. Stimulate oral apertuta through exercises.

9. Treatment of Complications.

10. Diagnosis of recurrences.

## **6. Conclusions**

Prior to initiating RTP treatment, all patients should be protocoled to ensure that they present optimal oral conditions. In this way, local and systemic complications can be minimized during and after treatment and measures that can be adopted to reduce adverse effects can be established. We consider it vital to quantify resting and stimulated saliva production prior to the commencement of RTP, as any previously existing xerostomia must be treated to prevent complications during RTP. The utility of an oral assessment should be explained and the importance of maintaining good oral health should be stressed.

#### **Author details**

Paula Bonar Alvarez1 , Mario Perez-Sayans García1,2\*, Maria Elena Padín Iruegas3 and Abel García-García4

\*Address all correspondence to: perezsayans@gmail.com

1 Oral Medicine, Oral Surgery and Implantology Unit. Faculty of Medicine and Dentistry. Santiago de Compostela, Spain

2 Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain

3 Human Anatomy and Embryology area. Faculty of Physiotherapy. Department of func‐ tional biology and health sciences, Pontevedra, Spain

4 Oral Medicine, Oral Surgery and Implantology Unit. Department of Maxillofacial Surgery, Complejo Hospitalario Universitario, Spain

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