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Radiotherapy to the mouth and jaw lowers the jawbone's ability to heal for the rest of your life, so a dentist should check your teeth before treatment starts and take out any that are unlikely to last, giving the gums time to heal. Afterwards, careful dental care for life and telling your dentist about the radiotherapy before any extraction help prevent bone damage called osteoradionecrosis.
The current guideline is ISOO-MASCC-ASCO 2024 (Peterson et al.), which could be read only as an abstract: it rated the prevention best practices and surgical management as evidence-based with strong evidence, relied on informal consensus elsewhere, made no recommendation on leukocyte- and platelet-rich fibrin or photobiomodulation for prevention, and judged hyperbaric oxygen for prevention or management largely unjustified. NCI PDQ (2024) sets out the pre-treatment dental work for high-dose head and neck radiotherapy: decide which teeth need extracting (advanced caries near the pulp, moderate or severe periodontal disease, periapical lesions symptomatic within 90 days, traumatising appliances), evaluate as early as possible so extraction sites can heal, maintain hygiene, prescribe jaw exercises against trismus and monitor for osteoradionecrosis. MASCC/ISOO 2020 gives expert opinion that dental evaluation and treatment before cancer therapy are desirable. On timing, a 2026 meta-analysis of eight retrospective cohorts found no overall link between the extraction-to-radiotherapy interval and osteoradionecrosis but higher risk in Western populations starting within 7 or 14 days; a 2022 meta-analysis in IMRT found extraction before radiotherapy has not been proven to reduce osteoradionecrosis compared with after, to be weighed against delay. For established osteoradionecrosis NICE NG36 says consider surgery to remove necrotic bone with soft tissue cover, and hyperbaric oxygen or medical management only within a trial.
Why: Any extractions need time to heal before radiotherapy starts, and treatment should not be delayed waiting for dental work.
“A dental evaluation is scheduled as early as possible to allow sufficient time to complete any necessary treatment and for tissues to heal after dental extractions and professional periodontal care.”
US National Cancer Institute 2024 · Not graded (PDQ summary)
Why: Teeth like these are likely to need extraction later, and extraction from irradiated bone is the main trigger for osteoradionecrosis.
“Determine need for medically necessary dental extractions and potential change in occlusal vertical dimension, based on the following:”
US National Cancer Institute 2024 · Not graded (PDQ summary)
Why: Infection from teeth can spread locally and into the blood during treatment.
“An expert opinion complements this guideline: Although there was insufficient evidence to support the use of professional oral care for OM prevention, the panel is of the opinion that dental evaluation and treatment as indicated before cancer therapy are desirable to reduce risk for local and systemic infections from odontogenic sources.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (expert opinion)
Why: In Western cohorts, starting within one or two weeks of an extraction went with more osteoradionecrosis; overall the evidence is mixed and delay to cancer treatment carries its own risk.
“In Western populations, patients initiating RT within < 7 days or < 14 days after dental extraction demonstrated significantly elevated ORN risk (OR = 3.07, 95%CI: 1.52-6.21 and OR = 2.01, 95%CI:1.10-3.68, respectively).”
World Journal of Otorhinolaryngology - Head and Neck Surgery (Liu et al.) 2026 · Meta-analysis of eight retrospective cohorts (Newcastle-Ottawa quality assessed)
Why: Exercises reduce jaw stiffness (trismus); a clean mouth lowers the risk of infection and decay in teeth left dry by radiotherapy.
“Prescribe jaw opening and closing exercises to reduce risk of trismus”
US National Cancer Institute 2024 · Not graded (PDQ summary)
Why: Bone damage can appear years after radiotherapy, often after an extraction or an injury, and early signs (exposed bone, pain, swelling) are easier to treat.
“Monitor for risk of osteoradionecrosis, recurrent or new oral mucosal malignancy”
US National Cancer Institute 2024 · Not graded (PDQ summary)
Why: Dead bone does not heal on its own; removing it and covering the area with tissue that has a good blood supply is the treatment with the most support.
“Consider surgery to remove necrotic bone and to establish soft tissue coverage in people with osteoradionecrosis.”
NICE 2016 · [2016]
Why: Trials have not shown a clear benefit, and it is time-consuming and expensive.
“The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.”
ISOO, MASCC and ASCO (Journal of Clinical Oncology; Peterson et al.) 2024 · As stated in the abstract (individual grades not read)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
ISOO-MASCC-ASCO 2024 is the current international guideline; its abstract says the prevention best practices and surgical management are evidence-based with strong evidence, hyperbaric oxygen is largely unjustified, and no recommendation was possible for platelet-rich fibrin or photobiomodulation. Its individual recommendations could not be read. From the sources that could be read: an early dental assessment, extraction of teeth with a poor outlook before treatment with time to heal (NCI PDQ 2024; MASCC/ISOO 2020 expert opinion), jaw exercises and lifelong monitoring, and surgery for established osteoradionecrosis (NICE NG36 1.10.1), with hyperbaric oxygen or medical management only in trials (NICE NG36 1.10.2). How long to wait between extraction and radiotherapy is not settled: a 2026 meta-analysis found no overall effect but higher risk with under 7 or 14 days in Western cohorts, and a 2022 meta-analysis in IMRT found extraction before radiotherapy not proven better than after.
ISOO, MASCC and ASCO (Journal of Clinical Oncology; Peterson et al.) 2024 · US National Cancer Institute 2024 · MASCC and ISOO (Cancer; Elad et al.) 2020 · NICE 2016 · World Journal of Otorhinolaryngology - Head and Neck Surgery (Liu et al.) 2026 · Strahlentherapie und Onkologie (Balermpas et al.) 2022
Where it differs: Extracts only teeth that are clearly unsalvageable before modern intensity-modulated radiotherapy, accepting later extraction if needed, to avoid delaying treatment.
Evidence: Balermpas 2022 (seven studies, 875 patients, abstract read): "Tooth extraction before IMRT is more common than after IMRT, but dental extractions before compared to extractions after IMRT have not been proven to reduce the incidence of ORN. Extractions of teeth before IMRT have to be balanced with any potential delay in initiating cancer therapy."
Where it differs: Gives a course of hyperbaric oxygen before and after a tooth extraction in a previously irradiated jaw.
Evidence: ISOO-MASCC-ASCO 2024 calls hyperbaric oxygen for prevention and management largely unjustified on limited evidence; NICE NG36 limits it to trials for treatment.
ISOO, MASCC and ASCO (Journal of Clinical Oncology; Peterson et al.) 2024 · NICE 2016
Teeth that might cause trouble are often taken out before radiotherapy to the jaw, to lower the risk of the bone breaking down later. How long the sockets should heal before radiotherapy starts is not settled: waiting longer may help the jaw but delays cancer treatment, and the studies so far disagree.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Prevention best practices and surgical management of osteoradionecrosis are evidence-based with strong evidence “Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management.” | Evidence-based, strong evidence (as summarised in the abstract) | ISOO, MASCC and ASCO (Journal of Clinical Oncology; Peterson et al.) 2024 |
| No recommendation on leukocyte- and platelet-rich fibrin or photobiomodulation to prevent osteoradionecrosis “No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN.” | No recommendation possible | ISOO, MASCC and ASCO (Journal of Clinical Oncology; Peterson et al.) 2024 |
| Hyperbaric oxygen or medical management for osteoradionecrosis only within a clinical trial “Only consider hyperbaric oxygen therapy or medical management for treating osteoradionecrosis as part of a clinical trial.” | [2016] | NICE 2016 |
| Dental evaluation and treatment before cancer therapy are desirable | III (expert opinion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| No overall association between extraction-to-radiotherapy interval and osteoradionecrosis “No significant association was observed between the timing of pre-RT dental extraction and ORN risk in the overall population (OR = 0.99, 95%CI: 0.67-1.47)” | Meta-analysis of eight retrospective cohorts | World Journal of Otorhinolaryngology - Head and Neck Surgery (Liu et al.) 2026 |
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Dry mouth, teeth and taste after head and neck radiotherapy, Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Head and neck squamous cell carcinoma.