Periodontal therapy for patients before and after radiotherapy: A review of the literature and topics of interest for clinicians

Soluble urokinase plasminogen activator receptor (suPAR) is a potential biomarker of stage III-IV, grade C periodontitis through the impact of post-radiotherapy on head and neck cancer patients

BACKGROUND

The urokinase-type plasminogen activator receptor (uPAR) plays an essential function in leukocytes and endothelial homeostasis and, therefore, in the development of chronic periodontitis.

METHODS

The study enrolled 150 participants, 50 chronic periodontitis with head and neck cancer post radiotherapy (CP + HNC post-RT) patients, 50 chronic periodontitis (CP) without HNC patients, and 50 healthy controls. Clinical Attachment Loss (CAL), Probing Pocket Depth (PPD), Plaque Index (PI), and Gingival Bleeding Index (GBI) were recorded. An enzyme-linked immunosorbent assay (ELISA) was constructed to quantify serum (suPAR) levels.

RESULTS

Stage and grade of periodontitis were stage III-IV, grade C in patients (CP + HNC post-RT), stage I-III, grade A/B in patients (CP without HNC), and absent in (healthy). Chronic periodontitis with HNC post-RT patients presented a significantly higher proportion of suPAR levels (506.7 pg/ml) compared to chronic periodontitis without HNC and healthy controls (423.08 pg/ml and 255.9 pg/ml), respectively. A significant positive correlation was found between serum suPAR levels and CAL, PPD, PI, and GBI in the periodontal disease groups. ROC results of suPAR (AUC = 0.976 for CP + HNC post-RT, AUC = 0.872 for CP without HNC). Hyposalivation appeared in patients (CP + HNC post-RT; 0.15 [0.11-0.23] ml/min, P = 0.001) and (CP without HNC; 0.30 [0.25-0.41] ml/min, P = 0.001), compared to healthy controls; 0.35 [0.28-0.54] ml/min, P = 0.001).

CONCLUSION

The study showed a significant elevation in serum suPAR levels in CP + HNC post-RT patients compared to the CP without HNC and control groups.

CLINICAL TRIAL REGISTRATION

The study was registered retrospectively; clinicaltrials.gov identifier: NCT06529588. Date of registration: July 31, 2024 https://clinicaltrials.gov/study/NCT06529588 .

Interdisciplinary Collaboration in Head and Neck Cancer Care: Optimizing Oral Health Management for Patients Undergoing Radiation Therapy

Radiation therapy (RT) plays a crucial role in the treatment of head and neck cancers (HNCs). This paper emphasizes the importance of effective communication and collaboration between radiation oncologists and dental specialists in the HNC care pathway. It also provides an overview of the role of RT in HNC treatment and illustrates the interdisciplinary collaboration between these teams to optimize patient care, expedite treatment, and prevent post-treatment oral complications. The methods utilized include a thorough analysis of existing research articles, case reports, and clinical guidelines, with terms such as 'dental management', 'oral oncology', 'head and neck cancer', and 'radiotherapy' included for this review. The findings underscore the significance of the early involvement of dental specialists in the treatment planning phase to assess and prepare patients for RT, including strategies such as prophylactic tooth extraction to mitigate potential oral complications. Furthermore, post-treatment oral health follow-up and management by dental specialists are crucial in minimizing the incidence and severity of RT-induced oral sequelae. In conclusion, these proactive measures help minimize dental and oral complications before, during, and after treatment.

The effectiveness of Moringa oleifera in the preservation of periodontium after radiation therapy: An experimental animal study

Background

Radiation therapy produces reactive oxygen species, which have been linked to various degenerative conditions in periodontal attachment. This study aimed to assess the beneficial effects of aqueous Moringa oleifera leaf extract on the periodontium of albino rats exposed to fractionated gamma radiation.

Materials and methods

This experimental study involved 24 adult male albino rats divided into three groups: Group M received M. oleifera leaf extract (300 mg/kg) intraperitoneally for 14 days; Group R received 20 Gy fractionated gamma irradiation; and Group MR received the same M. oleifera regimen as Group M and then fractionated gamma irradiation dose as Group R. On the first and seventh days post-radiation, bone, cementum, and periodontal ligament samples were histologically and histomorphometrically examined.

Results

The periodontal ligament, alveolar bone, and cementum showed structural damage in Group R. A relative persistence of normal periodontal tissue structures was seen in Group MR, showing less disruption of the periodontal ligament and greater trabecular bone thickness than Group R. The histomorphometric analysis showed that the mean periodontal ligament width was highest in Group R7 (245.20 μm) and lowest in Group M7 (54.55 μm). In addition, the mean cementum width was highest in Group R1 (88.99 μm) and lowest in Group M1R1 (17.87 μm) and differed significantly between groups.

Conclusion

Within the limitations of this study, Moringa oleifera leaf aqueous extract showed the potential to reduce the adverse effects of radiation, control inflammation, and support tissue healing in a rat model.

Effects of different doses of ionizing radiation on alveolar bone repair in post-extraction tooth socket: an experimental study in rats

OBJECTIVE

This study aimed to evaluate the dose-response effects of ionizing radiation (IR) on alveolar bone repair and bone strength after tooth extraction.

MATERIALS AND METHODS

A total of 32 male Wistar rats were used in the study, 28 animals were included in the final analysis, and n = 7 for each experimental group. Mandibular first molars were extracted. After 7 days, the animals were randomly divided into four groups according to single-dose irradiation: NIr, control group; Ir15, irradiated at 15 Gy; Ir20, irradiated at 20 Gy; and Ir30, irradiated at 30 Gy. The tooth extraction sites were subjected to micro-computed tomography (micro-CT), histological, histomorphometric, and biomechanical analyses 14 days after extraction. Data were analyzed using one-way ANOVA followed by Tukey's post hoc test (α = 0.05).

RESULTS

Micro-CT analysis revealed that IR led to lower values of bone volume (BV, in mm3) (0.68 ± 0.08, P < 0.001) and bone volume fraction, ratio of the segmented bone volume to the total volume of the region of interest (BV/TV, in %) (44.1 ± 8.3, P < 0.001) for the Ir30 group compared to the control group. A significantly lower amount of newly formed bone was observed in the Ir30 (P = 0.005) than in the Ir15 group. The histomorphometric results of quantification of bone matrix neoformation and the micro-CT were in agreement, demonstrating greater damage to the Ir30 group. IR30 cells showed a lower percentage of densely packed collagen than control cells. No significant differences were found in the biomechanical parameters.

CONCLUSION

IR affects alveolar bone repair. A dose of 30 Gy reduced the bone healing process owing to a smaller amount of newly formed bone and a lower percentage of densely packed collagen. Therefore, a dose of 30 Gy can be used to successfully establish an animal model of an irradiated mandible that mimics the irradiated clinical conditions.

CLINICAL RELEVANCE

Radiotherapy can lead to severe side effects and tooth extraction is a major risk factor. A proper understanding of the pathological mechanisms of radiation in alveolar bone repair requires the establishment of a suitable animal model of clinical conditions.

Association between tooth extraction during radiotherapy and the risk of osteoradionecrosis in patients with head and neck cancers

PURPOSE

It is commonly recommended that tooth extraction should be performed prior to radiotherapy (RT) in patients with head neck cancer to prevent osteoradionecrosis (ORN). However, doctors still occasionally encounter patients who require tooth extraction during RT. This study aimed to determine the risk of ORN in patients who undergo tooth extraction during RT.

METHODS

Data were collected from Taiwan's National Health Insurance Research Database. We retrospectively enrolled 24,412 patients with head and neck cancer treated with radiotherapy between 2011 and 2017. The associations between ORN and demographic characteristics, timing of tooth extraction, and treatments were examined using univariate and multivariable Cox proportional hazards regression models.

RESULTS

A total of 24,412 head and neck cancer patients were enrolled; 133 patients underwent tooth extraction during RT and 24,279 patients did not undergo tooth extraction during RT. Tooth extraction during RT was not associated with a significantly higher risk of ORN (hazard ratio [HR] = 1.303, P = 0.4862). Tumor site, RT dose ≥ 60 Gy, age < 55 y/o, mandibulectomy, chronic periodontitis, and chemotherapy were significantly associated with a higher risk of ORN.

CONCLUSION

The risk of ORN in head and neck cancer is not significantly different between patients who undergo tooth extraction during RT and patients who do not undergo tooth extraction during RT.

Conservative orthodontic treatment for severe pathologic migration following total glossectomy: A case report

Glossectomy combined with radiotherapy causes different levels of tongue function disorders and leads to severe malocclusion, with poor periodontal status in cancer survivors. Although affected patients require regular access to orthodontic care, special considerations are crucial for treatment planning. This case report describes the satisfactory orthodontic management for the correction of severe dental crowding in a 43-year-old female 6 years after treatment for tongue cancer with total glossectomy combined with radiotherapy, to envision the possibility of orthodontic care for oral cancer survivors. Extraction was performed to correct dental crowding and establish proper occlusion following alignment, after considering the possibility of osteoradionecrosis. Orthodontic mini-implants were used to provide skeletal anchorage required for closure of the extraction space and intrusion of the anterior teeth. The dental crowding was corrected, and Class I occlusal relationship was established after 36 months of treatment. The treatment outcome was sustained after 15 months of retention, and long-term follow-up was recommended.

Tooth extractions prior to chemoradiation or bioradiation are associated with weight loss during treatment for locally advanced oropharyngeal cancer

PURPOSE

Prior to radiotherapy combined with chemotherapy (CRT) or biotherapy (BRT) for oropharyngeal squamous cell carcinoma (OPSCC), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. The effect of tooth loss on body weight loss and tube feeding (TF) dependency during CRT/BRT is unknown. This study aimed to evaluate the effect of incomplete dentition, tooth extractions prior to CRT/BRT, and the subsequent loss of functional units on (1) weight loss during CRT/BRT and (2) the need for TF during CRT/BRT for OPSCC.

METHODS

OPSCC patients treated with CRT/BRT between 2013 and 2016 were included in this retrospective cohort study. Dental status was determined during the dental assessment at first visit and after tooth extractions prior to the start of CRT/BRT. Weight loss during CRT/BRT was scored dichotomously, comparing weight loss > 5% to stable or increased weight. Potential factors associated with weight loss were identified, including patient, tumor, and treatment characteristics.

RESULTS

Seventy-seven OPSCC patients were included. Forty patients (52%) experienced weight loss > 5% during CRT/BRT. Extractions were performed in 66% of the OPSCC patients. The mean number of extracted teeth was 4.1 ± 5.6 per patient. Tooth extractions prior to CRT/BRT were associated with weight loss > 5% during CRT/BRT (HR 1.130 (95% CI 1.011-1.262), p = 0.031). None of the dental status-related parameters showed any significant associative value for TF during CRT/BRT.

CONCLUSIONS

Pre-CRT/BRT tooth extractions intended to reduce the risk of ORN, are a risk factor for weight loss during CRT/BRT for OPSCC.

TRIAL REGISTRATION NUMBER

This study was approved by the medical ethics committee of the MUMC + (METC 2020-1589) on July 28, 2020.

Oral management strategies for radiotherapy of head and neck cancer

Radiotherapy, often with concomitant chemotherapy, has a significant role in the management of head and neck cancer, however, radiotherapy induces adverse events include oral mucositis, hyposalivation, loss of taste, dental caries, osteoradionecrosis, and trismus, all of which have an impact on patients' quality of life. Therefore, it is necessary to implement oral management strategies prior to the initiation of radiotherapy in patients with head and neck cancer. Since 2014, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines) have enumerated the "Principles of Dental Evaluation and Management (DENT-A)" in the section on head and neck cancers, however, oral management was not explained in detail. Oral management has not been achieved a consensus protocol. The aim of this literature is to show that oral management strategy include removal infected teeth before the start of radiotherapy to prevent osteoradionecrosis, oral care for preventing severe oral mucositis to support patient complete radiotherapy during radiotherapy, and prevent of dental caries followed by osteoradionecrosis after radiotherapy.

Identification of single nucleotide pleomorphisms associated with periodontal disease in head and neck cancer irradiation patients by exome sequencing

OBJECTIVE

Periodontal disease (PD) is a common oral complication in patients with head and neck cancer (HNC) undergoing radiation therapy (RT). Our objective was to identify candidate single nucleotide polymorphisms (SNPs) associated with PD in radiation-treated patients with HNC.

STUDY DESIGN

DNA was extracted from the saliva of patients with HNC (n = 69) before RT. Clinical attachment loss (CAL) increment greater than 0.2 mm over 24 months after RT was used to define PD progression. After exome sequencing, SNPs associated with post-RT PD progression were identified by using logistic regression and homozygosity analyses. The web tools STRING, the Database for Annotation, Visualization and Integrated Discovery (DAVID), GeneCodis, and Ensembl Variant Effect Predictor were used for functional analysis.

RESULTS

Of the 48 patients with HNC with post-RT PD progression, 24 had no tooth with 5 mm or greater pocket depth before RT, whereas of the 21 patients with HNC without progression, 11 had PD initially. A total of 330 SNPs (249 genes) with over-represented homozygous genotype (98.5% variant allele) were found to be associated with post-RT PD. Sixty of these corresponded to PD-related pathways, including previously identified genes. In patients with HNC with post-RT PD progression, SNPs were found in genes (n = 10) in contrast to those without progression (n = 7).

CONCLUSIONS

The SNPs of collagen genes were identified, potentially defining susceptibility to PD in patients with HNC, and this could be further investigated to characterize PD drug targets.

Disease-induced and treatment-induced alterations in body composition in locally advanced head and neck squamous cell carcinoma

BACKGROUND

Chemoradiation or bioradiation treatment (CRT/BRT) of locally advanced head and neck squamous cell carcinoma (LAHNSCC) comes with high toxicity rates, often leading to temporary tube feeding (TF) dependency. Cachexia is a common problem in LAHNSCC. Yet changes in body composition and muscle weakness during CRT/BRT are underexplored. Strong evidence on the effect of TF on body composition during treatment is lacking. The aim of this cohort study was to assess (i) the relationship of fat-free mass index (FFMI) and handgrip strength (HGS) with CRT/BRT toxicity and outcome, (ii) body composition in patients treated with chemoradiation (cisplatin) vs. bioradiation (cetuximab), and (iii) the effect of the current TF regime on body composition and muscle strength.

METHODS

Locally advanced head and neck squamous cell carcinoma patients treated with CRT/BRT between January 2013 and December 2016 were included (n = 137). Baseline measurements of body composition (bioelectrical impedance analysis) and HGS were performed. Toxicity grades (Common Terminology Criteria for Adverse Events) were scored. In a subset of 69 patients, weight loss, body composition, and HGS were additionally assessed during and after CRT/BRT. TF was initiated according to the Dutch guidelines for malnutrition.

RESULTS

In this cohort (68% male, mean age 59 ± 8 years), the incidence of baseline muscle wasting, defined as FFMI < P₁₀ , was 29%. Muscle wasting was present in 23 of 100 (23%) chemoradiation patients and 17 of 37 (46%) bioradiation patients (P = 0.009). Muscle-wasted patients required more unplanned hospitalizations during CRT (P = 0.035). In the chemoradiation subset, dose-limiting toxicity was significantly higher in wasted vs. non-wasted patients (57% vs. 25%, P = 0.004). Median follow-up was 32 months. Multivariate Cox regression analysis identified muscle wasting as independent unfavourable prognostic factor for overall survival [hazard ratio 2.1 (95% CI 1.1-4.1), P = 0.022] and cisplatin as favourable prognostic factor [hazard ratio 0.3 (95% CI 0.2-0.6), P = 0.001]. Weight and HGS significantly decreased during CRT/BRT, -3.7 ± 3.5 kg (P < 0.001) and -3.1 ± 6.0 kg (P < 0.001), respectively. Sixty-four per cent of the patients required TF 21 days (range 0-59) after CRT/BRT initiation. Total weight loss during CRT/BRT was significantly (P = 0.007) higher in the total oral diet group (5.5 ± 3.7 kg) compared with the TF group (3.0 ± 3.2 kg). Loss of FFM and HGS was similar in both groups.

CONCLUSIONS

In LAHNSCC patients undergoing CRT/BRT, FFMI < P₁₀ is an unfavourable prognostic factor for overall survival, treatment toxicity, and tolerance. Patients experience significant weight and FFM loss during treatment. Current TF regime attenuates weight loss but does not overcome loss of muscle mass and function during therapy. Future interventions should consider nutritional intake and additional strategies specifically targeting metabolism, loss of muscle mass, and function.