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To extract or not extract teeth prior to head and neck radiotherapy? A systematic review and meta-analysis

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A Comment to this article was published on 28 December 2022

Abstract

Purpose

Teeth with poor prognosis are generally recommended to be extracted prior to head and neck radiotherapy (RT) to reduce the risk of developing osteoradionecrosis (ORN), although controversies have been reported. The present systematic review aimed to determine whether tooth extraction prior to head and neck RT may be associated with a reduced risk of developing ORN compared to dental extraction during or after RT.

Methods

The review protocol was registered in PROSPERO (CRD42021241631). The review was reported according to the PRISMA checklist and involved a comprehensive search of PubMed, Scopus, Embase, Cochrane Library, LILACS, and Web of Science, in addition to the gray literature. The selection of studies was performed in two phases by two reviewers independently. The risk of bias of individual studies was analyzed using the Joanna Briggs Institute checklist for cross-sectional studies, and the certainty of evidence was assessed using the GRADE tool.

Results

Twenty-eight observational studies were included in the qualitative synthesis, which showed substantial heterogeneity regarding the association between the timing of tooth extraction and ORN development. Twenty-seven of 28 studies were pooled in a meta-analysis that demonstrated a significant association between an increased risk of ORN and post-RT tooth extraction (odds ratio: 1.98; 95% CI: 1.17–3.35; p = 0.01).

Conclusion

It was confirmed with moderate certainty that dental extractions should be performed prior to the start of head and neck RT to reduce the risk of ORN.

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Fig. 1

adapted from PRISMA [55]

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The authors state that no codes or algorithms were used in the manuscript under consideration.

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Acknowledgements

The authors would like to gratefully acknowledge the Oral Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) for the careful manuscript review, especially Dr. Derek K. Smith from the Vanderbilt University Medical Center, Nashville TN, USA, Dr. Cherry L. Estilo from the Memorial Sloan Kettering Cancer Center, New York, NY, USA, and Dr. Erin Watson from Princess Margaret Cancer Centre, Toronto, ON, Canada. Also, the authors would like to thank the São Paulo State Research Foundation (FAPESP 2019/26676-7, 2019/09692-9, and 2018/02233-6) and the Brazilian National Council for Scientific and Technological Development (CNPq) for Dr. Alan R. Santos-Silva funding.

Consortium data

Consortium name

Oral Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC). Website: https://www.mascc.org/oral-care

Contact details (consortia representative)

Dr. Derek K. Smith, Vanderbilt University Medical Center, Nashville TN, USA

2525 West End Avenue. Room/Suite 1141, Nashville, TN, 37203

Telephone: (615) 322-1895

E-mail: derek.k.smith@vumc.org

Consortium members

Cherry L. Estilo1, David Yang2, Deborah Saunders3, Erin Watson4

1Memorial Sloan Kettering Cancer Center, New York, NY, USA; 2Provincial Practice Leader in Oral and Maxillofacial Surgery for the BC Cancer Agency, Canada; 3Health Sciences North, Northeast Cancer Centre, Sudbury, Ontario, Canada and the Northern Ontario School of Medicine, Sudbury, Ontario, Canada; 4Princess Margaret Cancer Centre, Toronto, ON, Canada

Consortium additional details

The members of the consortium previously requested to not have author status; therefore, the group members were not included in the author’s list. The authors thanked the consortium for its contribution in the acknowledgements section.

Funding

This work was supported by Sao Paulo Research Foundation (FAPESP, Brazil) processes number 2019/26676–7 and 2019/09692–9 (PhD scholarships granted to Ana Gabriela C. Normando), and 2018/02233–6 (research grants given to Dr. Alan Roger Santos-Silva). The Brazilian National Council for Scientific and Technological Development (CNPq, Brazil) supports Dr. Alan R. Santos-Silva, Eliete Guerra, and Marcio Lopes as research grantees. None of the authors received research support from companies or similar organizations that may gain or lose financially through publication of this manuscript.

Data availability

All authors confirm that all data and materials as well as software application or custom code support their published claims and comply with field standards. The authors are aware of the journal’s individual policies on sharing research data in concordance with disciplinary norms and expectations.

Author information

Author notes

  1. Ana Gabriela Costa Normando and Maria Eduarda Pérez-de-Oliveira shared first authorship.

Authors and Affiliations

  1. Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil

    Ana Gabriela Costa Normando, Maria Eduarda Pérez-de-Oliveira, Márcio Ajudarte Lopes, Ana Carolina Prado-Ribeiro, Alan Roger Santos-Silva & Cherry L. Estilo

  2. Laboratory of Oral Histopathology, Health Sciences Faculty, University of Brasilia, Brasilia, DF, Brazil

    Eliete Neves Silva Guerra & David Yang

  3. Oral Medicine Department, AC Camargo Cancer Center, São Paulo, SP, Brazil

    André Caroli Rocha & Deborah Saunders

  4. Clinics Hospital of the Medical School of the University of São Paulo, São Paulo, Brazil

    André Caroli Rocha & Erin Watson

  5. Dental Oncology Service, Instituto Do Câncer Do Estado de São Paulo (ICESP-FMUSP), São Paulo, Brazil

    Thaís Bianca Brandão & Ana Carolina Prado-Ribeiro

  6. Departamento de Clínica E Odontologia Preventiva, Oral Medicine Unit, Universidade Federal de Pernambuco, Recife, PE, Brazil

    Luiz Alcino Monteiro Gueiros

  7. Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA

    Joel B. Epstein

  8. City of Hope Comprehensive Cancer Center, Duarte, CA, USA

    Joel B. Epstein

  9. College of Dentistry, University of Florida, Gainesville, FL, USA

    César Augusto Migliorati

Authors
  1. Ana Gabriela Costa Normando
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Consortia

on behalf of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO)

  • Cherry L. Estilo
  • , David Yang
  • , Deborah Saunders
  •  & Erin Watson

Contributions

All authors contributed to the study conception and design. Study design was performed by MAL, ACR, TBB, ACPR, and LAMG. Material preparation was performed by JBE and CAM, data collection was performed by AGCN and MEP, and analysis was performed by AGCN and ENSG. The first draft of the manuscript was written by AGCN and ARSS and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Alan Roger Santos-Silva.

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Ethics approval

This is a systematic review of the literature. The Research Ethics Committee from Piracicaba Dental School, University of Campinas, Brazil, has confirmed that no ethical approval is required.

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This is a systematic review of the literature; therefore, no human subjects were included, which justifies the absence of informed consent to patients to participate in the study.

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This is a systematic review of the literature; therefore, no human subjects were included, which justifies the absence of a consent for publication.

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The authors declare no competing interests.

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Normando, A.G.C., Pérez-de-Oliveira, M.E., Guerra, E.N.S. et al. To extract or not extract teeth prior to head and neck radiotherapy? A systematic review and meta-analysis. Support Care Cancer 30, 8745–8759 (2022). https://doi.org/10.1007/s00520-022-07215-y

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