global journal of oral science, 1-9 1 full mouth

Global Journal of Oral Science, 2021, 7, 1-9 1

E-ISSN-2414-2050 © 2021 Global Journal of Oral Science

Full Mouth Rehabilitation with Dental Implants in a Post Chemotherapy and Radiotherapy Cancer Patient – A Case Report

Faleh AL-Hojhouj1,2,3,* and Arwa Al-Sayed4

1Restorative, SF-ID Consultant and Clinical Associate Professor for Advanced Education, Restorative and Implantology; 2Dental Hospital Medical Director and Director of Implant Fellowship Program, King Saud Medical City, Riyadh, Saudi Arabia; 3Board Member of Implant Scientific Committee, Saudi Commission For Science Specialties, Riyadh, Saudi Arabia 4Head of Assessment and Examination Committee of the Saudi Board of Periodontics, Member the scientific committee of the Saudi Board of Periodontics, AC Professor at Genova University, Riyadh, Saudi Arabia

Abstract: Up until now, there has been controversy about whether patients who previously have had radiotherapy of the head and neck region are suitable candidates for dental implants. In the past, exposure of the maxilla and mandible to high-dose irradiation has been considered an essential contraindication for dental implantation [1]. On the other hand research studies have shown that survival after cancer therapy is so high, and the outcome from osseointegration therapy so favorable that osseointegration in the irradiated patient can be recommended. However, the osseointegration clinician should be aware of the risks and pitfalls of treating such patients [2]. Thus, prevention and treatment consider-ations for irradiated patients are essential to improve the implant survival rate [3]. This case report described a post-chemo-radiotherapy patient who undergone restorative treatment, full mouth dental implant was successful with a 100% survival rate in six years.

Keywords: Chemotherapy, radiotherapy, full mouth, dental implant.

INTRODUCTION

The patient diagnosed with malignancy is experiencing severe physiological discomforts due to the effect of the pathological process added by the effects of cancer treatment such as chemotherapy and radiotherapy or both. Combination therapy is always performed on patients with head and neck cancer, the same treatment which had been done to the case subject. According to statistics, ap-proximately 60%–80% of patients receive radiotherapy after surgery [4]. Radiotherapy is an important factor linked to implant failure. Studies from both animal subjects and human patients indicate that an irradiated bone has a greater risk of implant failure than a nonirradiated bone. This increase in risk may be up to 12 times greater [5, 6]. Radiotherapy causes different levels of damage to oral health. In addition to the changes in the hard and soft tissues in the oral cavity mentioned above, the damage of the oral mucosa, radiation caries, periodontal disease, dysfunction of muscles and joints, and imbalance of the nutritional status would all increase the risk of implant failure [7-10].

Head and neck cancer is a real presence in the dental-implant world--patients who undergo surgery, chemotherapy, and/or radiation often seek the assistance of dental-implant practitioners to restore

*Address correspondence to this author at the Board Member of Implant Scientific Committee, Saudi Commission For Science Specialties, Riyadh, Saudi Arabia; Tel: 00966505406391; E-mail: [email protected]

them to better function; other patients who have had implants in place for years will return with questions regarding how their treatment will be affected by the presence of their dental implant [11]. Some other data in the literature even suggest that the time interval between the end of tumor therapy and the dental implantation should be prolonged to 24 months because by that time most recurrences in patients with head and neck cancer usually had become manifest [12].

Nowadays, implant therapy is no longer considered impossible for patients who have received radiation treatment. However, the risk of osteoradionecrosis and failed osseointegration are barriers to implant therapy for this population [13]. To increase their quality of life, restorative treatment is necessary. Among the different restorative methods, implants are widely chosen for their good functional recovery and aesthetic effects [14]. After cancer treatment, it is the right of the patient to experience an improved quality of life. Thus, this case has shown how the post-chemo-radiotherapy patient achieved the success of undergoing a full mouth dental implant.

CASE REPORT

Patient Description

30 years old, male, Saudi national was referred to KSMC with a chief complaint of not having teeth in the

2 Global Journal of Oral Science, 2021, Vol. 7 AL-Hojhouj and Al-Sayed

entire upper jaw (Figure 1). The Patient lost his all upper and some of his lower teeth after receiving chemotherapy and radiotherapy in the year 2000 due to Malignant Nasal Carcinoma and was started dental treatment management in the year 2012.

Clinical Examination

In the clinical examination, there was no significant finding in the extraoral examination. TMJ shows 2 fingers maximum mouth opening (Figure 2), with thin upper lip and asymmetrical smile analysis. Patient oral soft tissues are within normal during the intraoral examination (Figure 3); hard tissue dentition revealed lower fixed partial dental prosthesis from Teeth # 34 – 45 a cantilever to replace teeth # 35, 36 & 46 and RCT teeth # 34,43,44 & 45 (Figure 4). Cyanotic and Edematous gingival tissue, Swollen, loss of stippling, 2-3 mm, Red-Cyanotic, Edematous, with flat margins, blunt and rolled up thinness, and generalized 3-4mm probing depth. Oral hygiene measurements and Periodontal Screening and Recording (PSR) were done, wherein Occlusion is applicable.

Radiographic interpretation includes OPG, PA, CBCT for Upper Jaw (Figure 5) then diagnostic cast and wax-up, risk factors for implants areas after the

chemotherapy & radiotherapy was assessed in addition to SAC classification were utilized as diagnostic tools.

Figure 1:

Figure 2: TMJ.

Figure 3: Oral soft tissues.

Full Mouth Rehabilitation with Dental Implants in a Post Chemotherapy Global Journal of Oral Science, 2021, Vol. 7 3

Intervention

The patient was seen by a maxillofacial surgeon for mouth opening and TMJ and was recommended to place implants regularly while the prosthodontic recommended surgical crown lengthening, post and core then crowns for all restorable teeth except # 34 & 45, then Endodontic recommended RCT for the Inadequate Root Canal Treatment # 33 - 44. According to examinations done, ruled outpatient dental diagnosis were generalized mild plaque-induced gingivitis, non-restorable teeth # 34 & 45, inadequate root canal treatment teeth # 34, 43, 44 & 45, defective crowns teeth # 34 – 45 and multiple periapical lesions teeth # 32, 31, 41 & 42. The proposed treatment plan was single implant placement at area of # 15,13,11,21, 23,25,35,34 & 45 with internal sinus left (crystal approach) 15 & 25 with an alternative treatment plan of upper RPD. Implant surgical treatment plan utilized were Straumann # 15 – 25, size 4.1 x 10 (BL – SLActive) # 35,34 & 45: 4.1 x 4.8 x10 SP, and two-stage technique with internal sinus lift (crestal approach) for teeth # 15 & 25 surgical technique.

Phase I & II therapy includes Perio: OHI + scaling and Polishing of all teeth, FPD Removal and RCTs, Post & cores (Figure 6) were done then upper RPD.

DISCUSSION

Majority of articles dealing with standard surgical procedures to rehabilitate edentulous jaws use 4 to 6 implants [15]. In most cases; dental implants are the best tooth-replacement option out there. However, certain patients may not be suitable for dental implant treatment. These include patients who have undergone a significant amount of radiation therapy, for the treatment of cancer, particularly in the head or neck area. Higher risk of dental implant failure, anyone who has experienced radiation therapy and would like to get dental implants should consider the fact that their risk of dental implant failure will be significantly higher than that of other patients. The eligibility for dental implants after radiation therapy can depend on where in the body cancer was treated. Modern medicine often allows radiation treatment today to be focused on a single area, so if you were given radiation therapy on

Figure 4: Hard tissue dentition.

Figure 5: Radiographic Examination.


Figure 6: Phase 1 and II therapy.

Surgical Phase


Prosthetic Phase


Patients’ Response to Treatment

Figure 7: Recall after 6 years.

any area of the body or organ further down, such as the liver or breast, and the treatment was very focused, will allow patient to undergo dental implants. Radiation on the head or neck is likely to have caused more damage to the jaw, which makes the patient an unsuitable candidate for dental implants [16].

Implants have been widely used in restorative treatment for patients who have undergone head and neck cancer surgery. With the development of combination treatment of head and neck cancer, radiotherapy has been a common means of therapy. However, it could induce various changes in hard and


soft tissues and reduce the success and survival rate of the implants. Some researchers, using either animal models or clinical studies, have shown that certain strategies could be used for improving the survival rate of implants [17].

Radiotherapy leads to a considerable number of difficulties in implant treatment. For example, the tissue in the irradiated area usually leads to a reduction of the vascular portion and cells and hypoxia [18-20]. These changes lead to the destruction of osteoblasts and impaired bone modeling and remodeling which even cause osteoradionecrosis (ORN) [21]. Meanwhile, the radiotherapy may cause reduced saliva secretion and an imbalance of the peri-implant flora. All these factors increase the risk of implant failure. To solve this problem, many strategies have been used in clinical practice, and some have achieved ideal effects. However, every method has its limitations, and the applications and risks of differ-ent methods should be discussed further. Thus, the exploration of suitable ways to improve the retention of implants after radio-therapy needs further study.

Implants placed in the mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome [22].

Dental implants provide an important role in the oral rehabilitation of oral cancer patients. There may be an increased risk of implant failure in free flap bone that has been irradiated [23].

CONCLUSION

Irradiated bone is a challenging environment for implant placement. Successful rehabilitation of irradiated patients with implant-supported prostheses is multifactorial. Although the retrospective design of this study could be affected by selection and information biases in the results, leads to believe that immediate [24] and progressive [25] loading protocols are not advisable in irradiated patients. We conclude that a delayed loading protocol will give the best chance of implant osseointegration, stability, and, ultimately, effective dental rehabilitation [26].

There are numerous individual considerations to take into account when determining whether dental

implants are applicable, post-radiation therapy. The best thing to do is to consult with the oncologist, and with the dental implant treatment provider. It is essential to seek personal advice from professionals that know the patient medical history before deciding on treatment [16].

Dental implantation will lead to an improvement in food intake, speech, and balance of the contour of the lower third of the face in these patients. Hence, we feel that because of the high osseointegration rate and the low incidence of side effects, dental implantation has a tremendous impact on the quality of life in such patients [27].

COMPLIANCE WITH ETHICAL STANDARDS

Disclosure of Potential Conflicts of Interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants

Not applicable.

Informed Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

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Received on 20-01-2021 Accepted on 10-03-2021 Published on 29-03-2021 DOI: https://doi.org/10.30576/2414-2050.2021.07.01 © 2021 AL-Hojhouj and Al-Sayed; Licensee Global Journal of Oral Science. This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

global journal of oral science, 1-9 1 full mouth

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