Matthew C. Ward, MD; Cathleen M. Petersen, BSN, RN; Jenene Noll, BSN, RN; Matthew S. Bernard, BA; Jeffrey G. Kuremsky, MD; Anita Patel, DMD; Carrie Baldwin, MD, DMD; Jackson Morgan, DDS; Vipul V. Thakkar, MD; Jennifer L. Atlas, MD; Daniel R. Carrizosa, MD; Roshan Prabhu, MD, MSc; Benjamin J. Moeller, MD, PhD; Zvonimir L. Milas, MD; Daniel S. Brickman, MD; Catherine H. Frenkel, MD; Michael T. Brennan, DDS, MHS

JAMA Otolaryngol Head Neck Surg. Published online 8 August 2024. doi:10.1001/jamaoto.2024.2353

Key Points

Question  Does a window of opportunity exist for extraction of nonrestorable teeth recommended at baseline to be performed immediately following radiation therapy (RT) to the head and neck?

Findings  In this cohort study, 50 patients were observed, 30 patients complied with post-RT extractions at a median (range) of 64.5 (13-152) days post-RT. The 2-year cumulative incidence of exposed bone after postradiation extractions was 40%.

Meaning  This study found that the rate of exposed bone was intolerably high, despite performing planned extractions soon after RT.

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 22 September 2023, and 10 June 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.