Oral Surgery · patient case question
Six months after completing radiotherapy she needs an extraction in the irradiated field. What is the principal concern?
Patient case: Oral pain during head and neck radiotherapy
Patient: Female, 61 years old
Chief Complaint: “My whole mouth is raw and I can barely eat.”
Background: Currently in week four of radiotherapy for a squamous cell carcinoma of the tonsil, with concurrent chemotherapy.
Current Findings: Diffuse erythema and confluent ulceration of the buccal and labial mucosa and the soft palate. The pain is generalised and clearly NOT of dental origin. No white plaques that can be wiped off. No individual tooth is tender to percussion. Salivary flow markedly reduced.
Show answer and explanation
Correct answer: C. Osteoradionecrosis
- A. Radiotherapy does not produce a bleeding tendency. Concurrent chemotherapy may cause thrombocytopenia, but that resolves after treatment ends.
- B. Local anaesthesia works normally in irradiated tissue.
- C. CORRECT. Irradiated bone is hypocellular, hypovascular and hypoxic. Surgical trauma in that field can precipitate osteoradionecrosis — non-healing exposed necrotic bone which is extremely difficult to treat. The risk is LIFELONG and rises with radiation dose, particularly above 60 Gy, and is greatest in the posterior mandible.
- D. Mucositis resolves within weeks of finishing radiotherapy and does not recur in response to surgery.
Note: This is why the extraction decision belongs BEFORE radiotherapy: remove any tooth of doubtful prognosis at least 2–3 weeks before treatment starts, so the socket can heal in non-irradiated bone. Afterwards, exhaust every restorative and endodontic option before considering extraction.