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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 423-425

Radiation caries in a nasopharyngeal carcinoma patient


1 Department of Oral Medicine and Radiology, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
2 Department of Periodontics, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
3 Department of Oral Medicine, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
4 Department of Oral Biology, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
5 Department of Prosthodontics, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates

Date of Submission27-May-2019
Date of Decision22-Oct-2019
Date of Acceptance10-Nov-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Shishir Shetty
College of Dentistry, Gulf Medical University, Ajman
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_90_19

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  Abstract 


Radiotherapy (RT) is an important modality in the management of malignancies of the head and neck region. Like any other modality, RT has certain undesirable effects on the oro-facial structures. Radiation caries is one of the undesirable effects of radiation. To highlight the classical presentation, we are presenting a case of radiation caries in a 37-year-old male patient who had undergone radiotherapy for nasopharyngeal carcinoma.

Keywords: Prevention, radiation caries, radiotherapy


How to cite this article:
Shetty S, Reddy S, Abdelmagyd H, Al-Bayati SA, El-Sayed W, Shon A. Radiation caries in a nasopharyngeal carcinoma patient. J Datta Meghe Inst Med Sci Univ 2019;14:423-5

How to cite this URL:
Shetty S, Reddy S, Abdelmagyd H, Al-Bayati SA, El-Sayed W, Shon A. Radiation caries in a nasopharyngeal carcinoma patient. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 11];14:423-5. Available from: http://www.journaldmims.com/text.asp?2019/14/4/423/289865




  Introduction Top


Nasopharyngeal carcinoma is a malignancy occurring in the head-and-neck region which is poorly differentiated and radiosensitive in nature. Owing to these characteristics, they are usually treated with radiation therapy (RT), sometimes in combination with chemotherapy without chemotherapy[1],[2] radiotherapy uses ionizing radiation as a therapeutic agent. Like any other therapeutic modality used in the treatment of cancer, radiotherapy has own set of early and late complications.[3] One of the late complications of radiotherapy especially of the head and neck region is radiation caries.[3],[4] In the following case report, we have tried to highlight the classical clinical; features of radiation caries in a patient treated with radiotherapy for nasopharyngeal carcinoma.


  Case Report Top


A 37-year-old male patient reported to our department with complaints of multiple decayed teeth in both upper and lower jaws since 7 months. The patient also stated that he noticed pin-point black spots on the edges of his teeth 7 months back. These spots gradually increased in size over the past 7 months. Although none of them were associated with pain. The patient was diagnosed with nasopharyngeal carcinoma 3 years back at Regional Cancer Center. He received radiotherapy for 7 weeks. Concomitantly, he also received chemotherapy (Cisplatin and 5- fluorouracil). The patient had visited a private dentist in his native before undergoing radiotherapy for the restoration of decayed teeth and scaling. Metal crowns were made for the decayed teeth in the back region of upper and lower jaws. The patient's cigarette smoking habit for 10 years (10 cigarettes/day). His habit index was calculated 10 × 10 = 100. However, he had stopped the habit since the past 3 years. He was moderately built and moderately nourished, well oriented in time place and person. His vital signs within normal range. His height = 1.6 m, weight = 62 kg and body mass index = 23.25 kg/m2. In the extraoral examination, there was loss of facial hair in a symmetric fashion [Figure 1]. None of the lymph nodes in the cervicofacial region were palpable.
Figure 1: Clinical photograph of the patient showing loss of facial hair secondary to radiotherapy

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On examination of intraoral hard tissues, there was blackish discoloration of the incisal edges of maxillary and mandibular incisors [Figure 2], [Figure 3]. Cusp tips of canines, premolars, and molars also showed similar features. Thirty-six and 37 had deep cavitation involving the pulp. The blackish areas on the edges and cusps were rough on probing.
Figure 2: Clinical photograph showing caries on incisal edges of maxillary anterior teeth

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Figure 3: Clinical photograph showing caries on incisal edges of mandibular anterior teeth

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Based on the history given by the patient and the dental findings, a diagnosis of radiation caries type 2 was made. An intraoral periapical [Figure 4] was made in relation to 37 and 38 region which revealed radiolucency approximating the pulp. The patient was subjected to through oral prophylaxis 7 all the decayed areas were restored with glass ionomer cement. The posteriors were also restored with a temporary restorative material. The patient was prescribed fluoridated toothpaste and asked to keep sipping water containing pinch of common salt and was also prescribed commercially available salivary substitute. However, due to logistical issues, long-term follow-up of the patient was not possible.
Figure 4: Intraoral periapical radiograph showing radiolucent areas in relation to the crown of 1st and 2nd molar

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  Discussion Top


In the current context, RT plays a pivotal role in the management of patients with head-and-neck cancer but is simultaneously associated with some undesired reactions.[5] The clinical sequence usually the following radiotherapy includes events such as mucositis, decreased salivary output, dysgeusia, osteoradionecrosis, and radiation caries.[6] The link between radiation-induced xerostomia, alterations in the salivary secretion and formation of radiation-induced caries was studied as early as 1938.[5] Apart from radiation-induced xerostomia, key alterations in the saliva following radiotherapy include increase in the viscosity and a decrease in the pH of saliva.[7] the alterations in the salivary flow and component were the cause of radiation caries in our patient, who had radiotherapy for nasopharyngeal cancer. Researchers have come out with different methods of the classification of radiation caries.[8]

In someone of the earliest classification, Baden in 1970, three main types were specified. The first type the caries encircles the tooth near the neck region. This type of radiation caries is highly prone to crown amputations when subjected to occlusal forces. In the 2nd type, there is a brownish-black discoloration of the tooth crown. The 2nd type is also characterized by wearing off in relation to the occlusal surface of posterior teeth and incisal edges of anterior teeth. The third type of is characterized by a spot depression which tends to initiate from incisal or occlusal edges and later spread to labial or buccal surfaces.[9] Based on the above classification, our case was similar was categorized under Type 3.

The management of radiation caries usually will depend on preventive aspects rather than treatment of caries once it has occurred.[6] In has been observed that the use of certain cytoprotective drugs such as amifostine, decreases the damage to salivary gland tissue. These radioprotective agents make the salivary gland tissue less sensitive to radiation-induced damage.[10] There was no history of any such radioprotector usage in our patient. The patient education, fluoride prophylaxis, salivary substitutes, and sialagogues are the other important aspects that need to be taken into consideration during or after radiotherapy. Another popular salivary stimulant that can be used post-radiotherapy to stimulate salivary production is xylitol; it is also believed to hasten sugar clearance and improve buffering capacity.[10] In our patient, artificial saliva was used to neutralized radiation-induced xerostomia.

Restoration of radiation caries is a major hurdle in posterior stress-bearing areas where high occlusal forces challenge the use of conventional glass-ionomer cements. It has been suggested by researchers that the use of dental amalgam over a fluoride-releasing glass-ionomer should be preferably used instead of composite resins.[11] It has been suggested that in patients with radiation-induced xerostomia, the chances of marginal gap formation and subsequent recurrent caries are high if composites are to be used.[11] In our patient, the anterior was restored with glass ionomer filling and temporary filling was done for the posteriors. Unfortunately, the patient could not turn up for the permanent fillings.


  Conclusion Top


The important message that we learn from this case report is the importance of preventive treatment. Had the preventive measures been in place before the radiotherapy, the complications would not have occurred. It is therefore important for all the dentists and radiotherapists to work and coordinate as a team to reduce the occurrence rate of radiation-induced caries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toya R, Murakami R, Saito T, Murakami D, Matsuyama T, Baba Y, et al. Radiation therapy for nasopharyngeal carcinoma: The predictive value of interim survival assessment. J Radiat Res 2016;57:541-7.  Back to cited text no. 1
    
2.
Kamio Y, Sakai N, Takahashi G, Baba S, Namba H. Nasopharyngeal carcinoma presenting with rapidly progressive severe visual disturbance: A case report. J Med Case Rep 2014;8:361.  Back to cited text no. 2
    
3.
James JM, Puranik MP, Sowmya KR. Radiation induced caries. Int J Health Sci Res 2016;6:343-51.  Back to cited text no. 3
    
4.
Lakshman AR, Kanneppady SK, Castelino RL. Radiation caries in irradiated patient of nasopharyngeal carcinoma – A case report. Pac J Med Sci 2013;11:88-94.  Back to cited text no. 4
    
5.
Pillai DS, Babu SG, Castelino RL, Ram SS, Rao K, Kamath JS. Radiation caries in an irradiated patient with mucoepidermoid carcinoma of parotid gland Cukurova. Med J 2017;42:780-4.  Back to cited text no. 5
    
6.
Gupta N, Pal M, Rawat S, Grewal MS, Garg H, Chauhan D, et al. Radiation-induced dental caries, prevention and treatment – A systematic review. Natl J Maxillofac Surg 2015;6:160-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Cheng SC, Wu VW, Kwong DL, Ying MT. Assessment of post-radiotherapy salivary glands. Br J Radiol 2011;84:393-402.  Back to cited text no. 7
    
8.
Gupta N, Pal M, Rawat S, Grewal MS, Garg H, Chauhan D, et al. Radiation-induced dental caries, prevention and treatment – A systematic review. Natl J Maxillofac Surg 2015;6:160-6.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Shafer EG, Hine MK, Levi BM. Benign and malignant tumors of the oral cavity. In: Rajendran R, Sivapathasundaram B, editors. A Textbook of Oral Pathology. 6th ed. Philadelphia: WB Saunders; 2009. p. 440-3.  Back to cited text no. 9
    
10.
Rao K, Castelino RL, Shetty U, Babu GS. A review of post-radiotherapy complications necessitating urgency for further advances and innovations in radiotherapy. Austin J Radiol 2015;2:1026-.  Back to cited text no. 10
    
11.
Andrews N, Griffiths C. Dental complications of head and neck radiotherapy: Part 2. Aust Dent J 2001;46:174-82.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Case Report
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