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. 2024 Oct 1;150(10):851-858.
doi: 10.1001/jamaoto.2024.2353.

Planned Dental Extractions After Radiation Therapy

Matthew C Ward  1   2 , Cathleen M Petersen  3 , Jenene Noll  3 , Matthew S Bernard  3 , Jeffrey G Kuremsky  1   2 , Anita Patel  3 , Carrie Baldwin  3   4 , Jackson Morgan  3   4 , Vipul V Thakkar  1   2 , Jennifer L Atlas  1 , Daniel R Carrizosa  1 , Roshan Prabhu  1   2 , Benjamin J Moeller  1   2 , Zvonimir L Milas  1 , Daniel S Brickman  1 , Catherine H Frenkel  1 , Michael T Brennan  3   4
Affiliations

Planned Dental Extractions After Radiation Therapy

Matthew C Ward et al. JAMA Otolaryngol Head Neck Surg. .

Abstract

Importance: Nonrestorable teeth are recommended to be extracted prior to radiation therapy (RT). Occasionally, preradiation extractions introduce unacceptable delays in treatment initiation. Planned dental extractions immediately postradiation presents an alternative strategy, though outcomes are uncertain.

Objective: To evaluate the feasibility and safety of dental extractions immediately postradiation.

Design, setting, and participants: A prospective cohort study including patients planned for curative-intent RT but unable or unwilling to proceed with 1 or more extractions recommended pretreatment was carried out. From January 2020 to September 2022, 58 patients were screened and 50 enrolled. The dental care was performed at a single academic department and the cancer care at regional centers. Analysis took place between September 22, 2023, and June 10, 2024.

Exposure: On completion of RT, patients were recommended to complete extractions as soon as feasible, and ideally within 4 months.

Main outcomes and measures: The primary end point was the actuarial cumulative incidence of exposed alveolar bone noted by any practitioner at any time after extraction, calculated using Gray method with death as a competing risk. As a pilot study, no formal power calculation was performed; resources allowed for 50 evaluable patients.

Results: Among the 50 participants enrolled, RT was nonoperative for 32 patients (64%) and postoperative for 18 patients (36%). Intensity-modulated RT (IMRT) was delivered in all patients. Of the 50 patients, 20 (40%) declined dental extractions immediately postradiation and the remaining 30 (60%) underwent a median (range) of 8.5 (1-28) extractions at a median (range) of 64.5 (13-152) days after RT. The median (IQR) follow-up for survivors without exposed bone was 26 (17-35) months from the end of RT. The 2-year cumulative incidence of any exposed bone was 27% (95% CI, 14%-40%). The 2-year incidence of exposed bone for those who underwent dental extractions immediately postradiation was 40% (95% CI, 22%-58%) and 7% (95% CI, 0%-22%) for those who did not. Of the 13 who developed exposed bone: 4 resolved, 1 was lost to follow-up, and 8 were confirmed as osteoradionecrosis.

Conclusions and relevance: This cohort study found that postradiation dental extractions incur considerable risk, even if performed within a 4-month window.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Ward reported grants from Naveris, paid to institution; personal fees from Blue Cross Blue Shield NC, paid to institution; personal fees from Demos Medical Publishing, paid to institution; personal fees from Bayer, paid to institution; and personal fees from Exact Sciences, paid to institution outside the submitted work. Dr Atlas reported personal fees from Bristol-Myers Squibb, Regeneron pharmaceuticals, and Pfizer for consultanting/advisory board membership outside the submitted work; and consulting/advisory board work atBristol-Myers Squibb, Regeneron pharmaceuticals, and Pfizer. Dr Carrizosa reported personal fees from Bristol-Myers Squibb, grants from Merck, GlaxoSmithKline, Takeda, Elevation Oncology, AstraZeneca, Bristol-Myers Squibb, Ignyta, and Bayer, personal fees from OncLive/MJH Life Sciences, PER, Coherus, and Targeted Oncology outside the submitted work. Dr Frenkel reported personal fees from EMD Serono advisory board outside the submitted work. Dr Brennan reported personal/consultanting fees from Meira GTx, Lipella, and Sun Pharma. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Participant Flow Diagram
Figure 2.
Figure 2.. Cumulative Incidence of Exposed Bone in All Patients, and by Extraction Status, and Confirmed Osteoradionecrosis in All Patients and by Extraction Status
ORN indicates osteoradionecrosis; RT, radiation therapy.
Figure 3.
Figure 3.. Recursive Partition Tree Illustrating That Exposed Bone Occurred in Patients Who Underwent Extraction With a High Dose to the Oral Cavity
ORN indicates osteoradionecrosis; RT, radiation therapy.
See this image and copyright information in PMC

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