J. Oral Diag.

2019; 04:e20190001

ARTIGO DE REVISÃO

Endodontic treatment in patients previously

Abstract:
The head and neck region is an expressive site of malignant neoplasms. Radiation therapy
is a type of cancer treatment that can be used before or after surgical procedures, or in
contraindicated surgery cases. Radiotherapy can cause various side effects in the patient’s
mouth, including xerostomia, mucositis, radiation cavities, and osteoradionecrosis. Due
to the risk of osteoradionecrosis after dental extractions, endodontic treatment ends up
being the best preventive and therapeutic method. The purpose of this study is to review
the literature on endodontic treatment in cancer patients undergoing radiotherapy.

Keywords: Radiotherapy, Osteoradionecrosis, Endodontic treatment

1
Universidade de São Paulo, Dental School,
Department of Stomatology - São Paulo - SP
- Brasil.
2
Universidade de São Paulo, Dental School,
Department of Endodontic - São Paulo - SP
- Brasil.

Correspondence to:
Wellington Hideaki Yanaguizawa.
E-mail: [email protected]

Article received on January 28, 2019.

DOI: 10.5935/2525-5711.20190001

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 INTRODUCTION is usually associated with high rates of cell renewal.
Among the most frequent, one may notice xerostomia,
The survival rate and quality of life increase for pH alterations, mucositis, trismus, oportunistic infections
oncologic patients is based on many resources that are (oral candidiasis), dermatitis, dysphasia and dysgeusia7.
available nowadays. These means may even contribute Late effects may occur months or years after the
for the patient’s definite healing. The most frequent treatment and include periodontitis, radiation-induced
therapies for cancer treatment are surgical excision dental caries, xerostomia and osteoradionecrosis. The
(resection of the tumoral mass and surrounding tissues) complications may be temporary and disappear by the
and chemotherapy and/or radiotherapy. The two latter end of the treatment period, or permanent. Chronic
methods aim the destruction and/or growth inhibition complications need follow-up by the dental clinician8.
of neoplastic cells by interfering in cell division and Total doses of absorbed radiation, type of
acting on the the metabolism of cells that bear a large radiation therapy, frequency of application, tissues
mitotic activity¹. involved, tumor stage, age and the patient’s overall health
The radiation received during the radiotherapeutic condition influence the intensity of the effects9,10.
treatment may result in several alterations at the Radiation applied in oncologic patients induces
maxillofacial complex. Thus, a multidisciplinary considerable changes in the bone homeostasis, hence
approach thas includes a dental treatment plan should resulting in decreased osteoblastic activity, osteocytes
always precede radiotherapy in order to minimize the destruction, bone marrow fibrosis and reduction of
radiation effects on the patient². blood irrigation. These alterations affect the bone by
Endodontic treatment plays an important increasing the vulnerability to infections and reducing
role as far as maxillofacial pre and post irradiation its capacity of repair11.
treatment. Head and neck radiation therapy side effects Osteoradionecrosis is a late side effect that affects up
include severe caries lesions. Teeth extractions are not to fifty percent of all patients subjected to radiotherapy12.
recommended due to the risk of osteonecrosis, hence Some factors may promote the development of
the importance of endodontic therapy as treatment of osteoradionecrosis, such as immunesupressions, trauma,
choice for these patients³. exposure to chemical substances and infections (extensive
Other side effects associated with radiation therapy caries, severe periodontitis and periapical lesions). In the
may also interfere with the patient’s treatment. The absence of predisposing factors, osteoradionecrosis may
objective of this review was to analyze all information still occur13,14.
available in the literature with respect to endodontic Some authors mentioned that osteoradionecrosis
treatment in patients that had been previously submitted risk might fluctuate from the first 3-7 months after the
to radiotherapy and guidelines to turn endodontic end of the radiation therapy to 10 years15,16. Marx (1983)
sessions more comfortable for these patients. pointed that after the irradiation, bone tissue becomes
hypoxic, hypovascular and hypocellularized. All these
RADIATION THERAPY factors interfere with bone repair and this situation may
Radiation therapy has been employed since 1895 endure for long periods of time.
as an adjuvant treatment for malignant neoplasms. It In general, the risk of developing osteoradionecrosis
may be applied before or after the surgical procedure, will accompany the irradiated patient throughout his
or may be adopted when a surgical procedure is not entire life. The treatment is extremely complex, teeth
recommended4. extractions must be avoided at all costs, and all efforts
Exposure during radiotherapy affects both must be made to prevent extractions. Consequently,
neoplastic and healthy cells, which invariably induces endodontic treatment assumes an important role as an
toxicity in tissues adjacent to the tumor bed, such as alternative treatment in this group of patients17.
skin, oral mucosa, maxillary bones, teeth, salivary glands,
temporomandibular joints and facial muscles5,6. ENDODONTIC TREATMENT
Radiation therapy side effects may be classified Patients with head and neck malignant neoplasms
according to the time frame in which they occur: acute that will be subjected to radiotherapy treatment should
effects or late effects. Acute effects occur at the same preferably receive dental and endodontic treatment prior
period that the patient is subjected to the therapy and to radiation sessions in order to eliminate any form of

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disease present on the teeth and mucosa. During or after Complementary imaging exams (e.g. panoramic
radiotherapy, infections foci evolve more aggressively18. radiography and periapical radiographies) may be
Occasionally, the tumor growth is so severe that it performed before the first dental visit, so that endodontic
is not recommended to delay radiation therapy because treatment prescribed22.
of pre-radiotherapy dental treatment19. In those cases, When performing a periapical radiograph in
endodontic treatment with proper root canal sealing irradiated patients, it is recommended to protect the
is essential in oral health maintenance and side effects corners of the radiographic film with utility wax to
prevention13. possible trauma in the oral mucosa, thus avoiding to
Endodontic treatment should never be performed transform dormant bone necrosis into more severe bone
during the radiation therapy period. However, necroses22,23.
when the patient is having pain associated with an According to Rosales (2009), approximately
endodontic acute process, a treatment session must be 41% of patients that did not have a dental evaluation
performed, with medical consent, to relieve the patient’s performed before radiotherapy were in need of
symptomatology20. endodontic treatment. On the other hand, only 10.8%
A considerable variety of oral alterations may who had dental evaluation prior to radiotherapy had
occur by reason of irradiation, so numerous procedures to undergo canal treatment in the post-radiotherapy
must be cared for from the initial diagnosis until period24.
the endodontic procedures follow-up. Endodontic There are few studies that proposed to establish
sessions should be short because the patient might feel a safe time for initiation of endodontic therapy after
uncomfortable with keeping the mouth open for long radiotherapy. Shafer (1987) stated that the ideal period
periods. This situation may develop as a result of trismus for endodontic treatment would be from 60 to 120
in the muscles of mastication21. days after radiotherapy ends, at which time any bone
alterations would be less present. According to these
Diagnosis authors, the professional, however, had to an evaluate the
Diagnosis is obtained via a thorough clinical conditions of the oral cavity and the patient’s systemic
examination that aims to analyze signals and symptoms health20.
collected by means of subjective, objective and Several studies have shown that radiation therapy
complementary exams10. does not induce pulpal damage. Hutton (1974) and
Anamnesis must be comprehensive, enclosing Nickens (1977) noted no histological differences in pulp
previous and current medical history, radiotherapy tissue after being submitted to 70 Gy of irradiation25,26.
beginning and timeframe, dosage (Gy) and number of Knowles (1986) observed that decreased pulpal
therapy sessions. If necessary, the dental clinician has sensitivity was noticed only in teeth within or adjacent
to contact the patient’s oncologist9. to an irradiated field, while Kataoka (2011) noted a time-
The physical exam must include tooth mobility, dependent decrease in oxygen saturation levels in pulpal
horizontal and vertical percussion tests, temperature tissues submitted to radiation27,28.
pulpal tests and presence of cavities in all teeth with Cox (1976) stated that these complications may be
suggestion of lesions that involve the pulp. While reduced by dose fractionation, use of radiation protection
performing pulpal vitality tests, teeth may present devices, as well as the assessment and dental treatment
exaggerated response due to post-radiotherapy pulpal previously to radiation therapy4.
hyperemia. After radiation caries are established, most
teeth do not respond normally to temperature pulpal Anesthetic technique, rubber dam isolation, endodontic
tests. They present weak and late responses due to a access opening and odontometry
reduced pulpal blood supply that is related to fibrosis The anesthetic technique should be as atraumatic
of the inner layer of the blood vessels. This fibrosis as possible and appropriate to the area to be treated. The
occurs after radiation and may be responsible for patient presents a natural vasoconstriction of his/her
producing calcifications or irregular dentin1. At this blood vessels associated with radiotherapy. Therefore,
phase, a periapical radiography is recommended, to it is recommended to use local anesthetics without
verify alterations in the dentin or thickening of the vasoconstrictor especially in the region of the mandible.
pericemental membrane15. The incidence of osteoradionecrosis is about seven times

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greater in the mandible when compared to the maxilla. In the reliability of the results obtained by the electronic
addition, the clinician should avoid the intraligamentary apex locator22.
anesthetic technique to prevent trauma and possible A well performed odontometry is critical for
periodontal ligament necrosis22. these patients. The professional may always work before
Because of the loss of dental tissue caused by the apical foramen or cement-dentin junction limit,
dental caries, it is difficult to isolate these patients. In hindering later accidents of instruments or obturator
those cases, the practitioner must use several devices materials trespassing, overflow of chemical substances
to avoid the promotion of gum trauma associated and irrigating materials to the periapical tissues, in order
to the placement of clamps. Physical aggression to to avoid osteorradionecrosis33.
the periodontium may lead to alveolus necrosis and
subsequent osteorradionecrosis29. Root canal instrumentation, medication, obturation and
One of the techniques consists of anchoring follow-up
the rubber sheet to neighboring teeth by wrapping The mechanical chemical preparation phase is
several teeth under the rubber dam, and use of dental decisive for the success of endodontic treatment and
floss around the damaged teeth instead of using metal must be performed with great care and skill. The
clamps. When necessary, the clinician may rebuild the clinician must perform this step within the working
dental crown with restorative materials as composite length. In these patients, working length must always
resin30. Crown lengthening surgical procedures should be before the apical limit (on average, the working length
be avoided because of the high risk of developing is one millimeter in cases of necropulpectomy and two
osteorradionecrosis31. millimeters in cases of biopulpectomies22.
Since these patients may present decreased During the irrigation phase, it is essential to
salivary flow and / or dry mouth (xerostomia), the use maintain some reflux space for the chemical substance.
of artificial saliva and creams are recommended. The Some authors recommend the use of a fine needle
application should occur prior to rubber dam isolation, coupled with a measuring ring; the ring must be
reducing the discomfort during endodontic therapy22. regulated between the middle and apical thirds of
Montgomery (1977) suggested that endodontic the dental canal. This will avoid the overflow of the
treatment for patients that had previously been submitted irrigation solution, hence preventing an inflammatory
to radiotherapy should begin several months after the response at the periapical region34,35.
end of the treatment21. Due to trismus associated with According to Montgomery, head and neck
radiation therapy, he recommended that the patient radiation therapy patients may present facial muscles
exercised his muscles by opening his mouth to the trismus and ankylosis of the TMJ. These factors may
maximum for 20 times each morning, afternoon and limit the patient mouth opening and also result in a painful
evening, and did not use mouth opener. In extraordinary posture to the patient. Therefore, treatment should be
situations, Seto (1985) proposed that endodontic access performed in short sessions21. The instrumentation with
openings could occur in unusual locations such as buccal rotary or reciprocating endodontic motors is strongly
aspect of inferior incisors32. recommended for irradiated patients, because the
Root canal length measurements should preferably automated technique makes the treatment faster, more
be performed with the aid of an electronic apex locator comfortable and provides a very good cleaning efficiency
and confirmed by periapical radiography. Due to the and canal shaping36.
difficulties in the radiographic acquisition, as the film Since the irradiated patient is vulnerable to the
may injure the mucosa, the radiographic confirmation development of osteoradionecrosis and different levels
can be excused if the professional has experience over of depression of the immune state, some authors
the electronic device33. recommend the use of prophylactic antibiotics during
Patients irradiated in the head and neck region endodontic treatment. As a first choice, semisynthetic
generally present hyposalivation. Thus, it is important derivatives of penicillins such as amoxiline and ampicillin
that it be the lip hook of the electronic apex locator may be prescribed. If the patient is allergic to these
and the mucosa around it are moistened with saline drugs, the patient may use clindamycin. There are no
or artificial saliva, in order to promote the necessary major contraindications for the use of other drug groups
conductivity between the electrodes and thus increasing in these patients37. However, according to Andrade

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(2003) the use of antibiotic therapy during endodontic pulpitis, and for the prevention of osteoradionecrosis
treatment in irradiated patients is questionable3. He lesions development41. Endodontic treatment hinders
suggested that there is a reduced penetration of the tooth extractions, rehabilitates the patient with both
antibiotic at the bone tissue as a result of the local aesthetic and functional restoration of the teeth and
ischemia. improves their quality of life42.
In a study of primary teeth in irradiated children,
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Journal of Oral Diagnosis 2019