107 Redundant tooth loss prior to head and neck radiotherapy 5 Introduction Osteoradionecrosis (ORN) of the jaw is among the most feared late complications observed in patients with head and neck cancer (HNC) treated with radiotherapy (RT) [1]. Removal of teeth with a limited prognosis and identified as a potential cause of infection in the oral cavity prior to head and neck RT can be associated with a lower risk of developing ORN compared to performing tooth extractions after or during RT [2]. Therefore, it is important that the jaw areas receiving significant doses of radiation are free of potential sources of infection prior to RT. However, tooth extractions result in a decreased number of functional units and impair mastication and swallowing, contributing to a decreased health-related quality of life (QoL) [3-8]. In a recent study on patients with oropharyngeal squamous cell carcinoma (OPSCC), tooth extractions prior to therapy contributed to significant weight loss during RT combined with chemotherapy (CRT) or biotherapy (BRT) [9]. Since maintaining body weight is important for completion of planned RT and to support the recovery period, further weight loss caused by tooth extractions should be minimized or avoided as much as possible [10]. The original Dutch protocol which was re-evaluated in 2018 recommends comprehensive dental assessment of potential oral sources of infection at least 10 to 14 days prior to RT to allow adequate time for wound healing [11-13]. As described by Spijkervet et al., the risk of developing ORN starts at a RT dose of about 40Gy and increases with increasing radiation dose [1]. It is therefore desirable to eliminate oral sources of infection where the radiation fields will achieve an expected cumulative radiation dose of ≥40Gy [13, 14]. However, some of the extracted teeth may be redundantly extracted, due to the fact that the estimated radiation dose prior to RT appeared to be lower after completion of RT planning. Considering the impact of pre-RT tooth extractions on patients with HNC and the advancements in RT techniques, there is a growing demand to adopt a less radical approach to pre-RT extractions [3, 5, 6, 15, 16]. The first objective of this study was to gain insight into the number of teeth not necessarily extracted prior to planned RT. The second objective was to determine which patient or tumor characteristics are associated with the number of redundantly extracted teeth prior to RT.
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