Natália Rangel Palmier

Radiation-related caries assessment through the international caries detection and assessment system and the post-radiation dental index

OBJECTIVE Although radiation-related caries (RRC) are a well-known toxicity of head and neck radiotherapy, a clinical classification system for RRC has not yet been clinically validated. Therefore, the aim of this study was to assess whether the International Caries Detection and Assessment System (ICDAS) and the Post-Radiation Dental Index (PRDI) were viable methods for the assessment of RRC. STUDY DESIGN Clinicopathologic data and intraoral digital photographs of 60 patients (833 teeth) affected by RRC were assessed and classified according to the ICDAS and PRDI criteria. RESULTS A total of 814 (97.7%) teeth presented RRC lesions ranging from early stage to complete tooth destruction. Mean scores for the whole sample were 5 for ICDAS and 3 for PRDI, indicating that RRC were diagnosed predominately in late stages. ICDAS and PRDI criteria underestimate the clinical expressivity of RRC by not including the whole qualitative clinical spectrum of RRC, such as enamel cracks, delamination, dental crown amputation, surface color alterations, and atypical lesions topography (incisal/cuspal caries). CONCLUSIONS ICDAS and PRDI may not be considered viable for the assessment of RRC. The development of a specific clinical classification system is urgently needed to help clinicians recognize the peculiar patterns of RRC, particularly in incipient cases.

Feasibility of ICDAS and Post-Radiation Dental Index in Assessing Radiation-Related Caries

The treatment for head and neck cancer (HNC) which includes malignant tumours originating in the oral cavity, oropharynx, hypopharynx, larynx and central nervous system (CNS) – is based on multimodality protocols that include radiotherapy (RT). Although effective in the locoregional disease control, RT is associated with several toxicities in the tissues adjacent to the tumour including mucositis, radiodermatitis, hyposalivation, dysgeusia, dysphagia, trismus, radiation-related caries (RRC) and osteoradionecrosis, among others. It is estimated that 25% of the patients in this medical scenario will develop RRC after about 12 months after the RT conclusion. RRC, when compared to conventional caries, manifests in unusual dental topographies (cusp, incisal border, and cervical region near the cementoenamel junction), generates a brownish-black colour on enamel noncavitated surfaces, fissures, cracks and delamination; affects underlying dentin and rapidly progress leading to dental crown amputation. So far, there is no clinically validated detection and assessment system for RRC, which creates difficulties in standardizing early diagnosis and proper treatment. Therefore, the aim of the present study was to assess the feasibility of the Caries Detection and Assessment System (ICDAS) and Post-Radiation Dental Index (PRDI) in the RRC context. Clinicopathological data and intraoral digital photographs of 60 patients (833 teeth) diagnosed with RRC were classified according to the ICDAS and PRDI proposed criteria. Eight hundred and fourteen teeth (97.7%) were affected by RRC lesions in several clinical stages of progression, ranging from incipient areas of demineralization to generalized dental crown amputation. The median scores for the ICDAS and PRDI index were 5 and 3, respectively, indicating that most of RRC cases in this sample were predominately diagnosed in late stages. The development of the ICDAS and PRDI index did not consider clinical events highly prevalent in RRC patients such as enamel fissures and cracks, delamination, colour alteration on enamel non-cavitated surfaces and caries lesions affecting incisal and cuspal tooth surfaces. In conclusion, both ICDAS and PRDI index present low potential of clinical applicability in the context of diagnosis and assessment of RRC.

Cracked tooth syndrome in irradiated patients with head and neck cancer

OBJECTIVES The aim of this study was to assess the presence of enamel craze lines (ECLs), part of the spectrum of the so-called cracked tooth syndrome, on the surface of teeth irradiated in vivo. STUDY DESIGN Forty teeth extracted from patients with head and neck cancer were paired, matched, and equally divided into 4 groups: noncarious irradiated (G1); noncarious control (G2); radiation-related caries (RRC) (G3), and carious control (G4). Samples were examined for ECL detection with a fiberoptic transillumination device and photographed, and ECL mean size, number, and patterns of topographic distribution in tooth crown were determined. Groups were compared accordingly: G1 versus G2; G3 versus G4. RESULTS We analyzed 538 ECLs, of which 30.1% were found in noncarious irradiated teeth, 19.3% in noncarious controls, 27.6% in RRC, and 23% in carious controls. Non-carious irradiated teeth presented higher quantities of ECL than non-carious control (P < 0.05). Higher incidences of ECLs were identified in specific enamel topographies of anterior G1 and G3 samples (P <.05). There was no correlation between ECL size/numbers and radiation isodose delivery to teeth. CONCLUSIONS Increased incidence of ECLs may indicate weakened enamel structure in irradiated teeth, and this may play a role in the onset and progression of RRC.

MONOSTOTIC FIBROUS DYSPLASIA

A 63-year-old male was referred to the OROCENTRO Clinic Piracicaba Dental School due to a swelling at the right side of the face. Patient stated that first noted the swelling for over 20 years. The patient was submitted to multiple tooth extractions on the region due to pain. After extractions pain ceased, nevertheless the swelling kept growing. Extraoral examination revealed a hard swelling on the right side of the face causing elevation of the nose wing and deletion of nasolabial groove. Intraoral examination revealed a hard, normochromic swelling on the right maxilla affecting both palatine and vestibular surfaces with deletion of maxillary vestibule. Digital panoramic radiography showed a poorly defined radiopaque image with “ground glass” aspect. Computed tomography revealed a mixed density image affecting the floor of the maxillary sinus and vestibular and palatine cortical bone of the right maxilla. Incisional biopsy was performed under local anaesthesia on the vestibular surface of the right maxilla using a Trephina drill (7 mm X 180mm). Histopathological analysis presented fine branching curvilinear/irregular trabeculae of woven bone among a fibrous cellular stroma and was compatible with Monostotic Fibrous Dysplasia. Patient did not present signs of post-operatory infection or dehiscence and was referred to an appropriate treatment service for surgical planning.