The Risk of Osteoradionecrosis Associated With Dental Extractions Prior to Radiotherapy: A Systematic Review

Background : Head and Neck Cancer (HNC) patients have a risk of developing osteoradionecrosis (ORN) following radiotherapy (RT). Dental extractions are a recognised risk factor. The primary aim of this systematic review was to estimate the risk associated with pre-RT extractions. The secondary aim was to investigate the risk associated with post-RT extractions and both pre- and post-RT extractions in the studies identified. Methods: A systematic review was conducted using a PRISMA protocol. Electronic searches of Cochrane Library and OVID via Medline were undertaken between 2002-2023. Data extraction from the studies related to incidence of ORN and type of extraction was conducted by the authors to produce odds ratio values (OR) for each study and type of extraction. A meta-analysis was performed using a random effects model. Heterogeneity was investigated by sub-group analysis. Findings: Thirteen articles were included in this review. The odds ratio (OR) values for ORN following RT was calculated for each study, dependent on the type of extraction. Substantial heterogeneity was observed (I ² =62.1%(p=0.002)) for the Pre-RT analyses but not for the post-RT and both types of extractions. In the presence of this heterogeneity, an increased risk of ORN following pre-RT extractions was observed (OR= 2.77, 95% CI = 1.66-4.62). There was an increased risk of ORN associated with post-RT extractions (OR = 4.19, 95% CI = 2.917-8.08) and Both extractions (OR=7.96, 95% CI = 3.91,16.20). Subgroup analyses corroborated these findings. The study population attributable risk for the association of Pre-RT extractions with ORN is 28.53%(95%CI:21.34,31.73) Interpretation: This review suggests that Pre-RT extractions increase the risk of ORN compared to no extractions. Post-RT and both extractions further increase the risk of ORN. This supports current RCS guidelines.