Safety of Planned Dental Extractions Immediately after Radiation Therapy: First Report of a Prospective Observational Study

• Published in: International journal of radiation oncology, biology, physics Vol. 118; no. 5; pp. e44 - e45
• Main Authors: Ward, M.C., Petersen, C., Noll, J., Bernard, M.S., Kuremsky, J.G., Patel, A., Baldwin, C.A., Morgan, J.P., Thakkar, V.V., Atlas, J.L., Carrizosa, D.R., Prabhu, R.S., Moeller, B.J., Milas, Z.L., Brickman, D.S., Frenkel, C.H., Brennan, M.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.04.2024
• ISSN: 0360-3016; 1879-355X
• DOI: 10.1016/j.ijrobp.2024.01.100

Non-restorable teeth are recommended to be extracted prior to radiation therapy (RT). Occasionally, patients are unable or unwilling to complete the extractions, and RT delay can compromise survival. Some have proposed a safe “window” for extractions immediately post-RT which could improve time-to-treatment, but data is non-existent. We evaluated the feasibility and safety of dental extractions post-RT (D.E.Po.R.T.). After IRB-approval we performed a single-arm, single-institution prospective observational study. Patients were eligible if dental evaluation prior to curative-intent RT recommended ≥1 extraction, and the patient was unable or unwilling to proceed for any reason. Patients were recommended DEPoRT within 4 months of RT. The primary endpoint was the cumulative incidence of exposed alveolar bone. If exposed bone was noted by a non-dental provider (surgeon, radiation, or medical oncologist), dental referral was made for confirmation. Secondary objectives were to quantify the feasibility of DEPoRT, and to correlate outcomes with dosimetry and extraction timing. As a pilot study, no formal power calculation was performed; resources allowed for 50 evaluable patients. The actuarial cumulative incidence of exposed bone (and confirmed osteoradionecrosis) was calculated using Gray's method with death as a competing risk. No hypothesis testing was pre-specified. From December 2019 to September 2022, 58 were screened and 50 enrolled. Cancers were 96% oral or laryngopharyngeal and 96% squamous cell. Treatment was non-operative for 32 and postoperative for 18. IMRT was delivered in all, and 86% were treated bilaterally. The median of the mean oral cavity dose was 39.8 Gy (range 10.1-64.8). 36 received chemotherapy. Of the 50 patients, 20 declined DEPoRT and the remaining 30 underwent a median of 8.5 extractions (range 1-28) at a median of 64.5 days post-RT (range 13-152). Five deaths occurred, 1 underwent DEPoRT and 4 did not. The median follow-up from the end of RT for survivors without exposed bone was 25 months (IQR 17-34). The 2-year cumulative incidence of any exposed bone was 24% (95% CI 12-36%). The 2-year incidence of exposed bone for those who underwent DEPoRT was 40% (95% CI 22-58%) vs. 0% (95% CI NA) for those without DEPoRT. Of the 12 who developed exposed bone: 4 resolved, 1 was lost to follow-up and 7 were confirmed as osteoradionecrosis (ORN). Of the 7 with confirmed osteoradionecrosis, 2 died of cancer, 2 have been treated conservatively, 1 underwent surgery, 1 hyperbaric oxygen (HBO), and 1 both surgery and HBO. Post-radiation dental extractions incur significant risk, even if performed within 4-months. Further follow-up is required to determine if any benefits exist as compared to observation without extraction.