Radiation Biology

Presented by:
Mr Samuel Dushimirimana (BSc, MSc)
 CONTENTS
• BIOLOGICAL EFFECTS
EFFECT ON CELLS
1. DNA
• INTRODUCTION
2. CYTOPLASM
• RADIATION MEASUREMENTS 3. NUCLEUS
4. CHROMOSOMES
• RADIATION INJURY 5. PROTEINS
6. CELL DIVISION
• Terminologies 7. CELL DEATH

• TYPES OF RADIATION EFFECTS RADIATION EFFECT ON CRITICAL ORGANS

1.SKIN
• Stochastic effects 2. BONE MARROW
3. THYROID
• Deterministic (non-stochastic) effects 4. GONADAL
5. EYE
• Short-term effects (acute)
EFFECT ON ORAL TISSUES
• Long-term effects (chronic) 6. ORAL MUCOSA-MUCOSITIS
7. TASTE BUDS
• Somatic effects (late) 8. SALVARY GLANDS-XEROSTOMIA
9. TEETH- RADIATION CARIES
• Genetic effects 10.BONES-OSTEORADIO NECROSIS

• In-Utero Effects EFFECT ON WHOLE BODY

11.ACUTE RADIATION SYNDROME
• FACTORS DETERMINING BIOLOGICAL EFFECTS OF 12.HEMATOPOITIC SYNDROME
RADIATION 13.GASTROINTESTINAL SYNDROME
14.CARDIOVASCULAR SYNDROME
15.CENTRAL NERVOUS SYNDROME
INTRODUCTION
• Radiation biology is the study of the effects of ionizing radiation on
living systems.
• Radiation, is defined as the emission and propagation of energy
through space or a substance in the form of waves or particles.
• Ionizing radiation can be defined as radiation that is capable of producing
ions by removing or adding an electron to an atom.
• Particulate radiation ( made up of sub-atomic particles: alpha, beta radiations)
• Electromagnetic radiation (defined as the propagation of wave-like energy (without
mass) through space or matter: x-rays, gamma)
• Non-ionising radiation
Electromagnetic radiation spectrum
Depending on the radiation’s energy, the protection
measures vary
The longer the wavelength, the shorter the frequency of radiation,
and vice-versa
RADIATION MEASUREMENTS
RADIATION MEASUREMENTS
• Radiation can be measured in the same manner as other physical
concepts such as time, distance, and weight.
• The International Commission on Radiation Units and Measurement
(ICRU) has established special units for the measurement of
radiation.
• Such units are used to define four quantities of radiation:
• Exposure.
• Dose.
• Dose equivalent.
• Radioactivity
• At present, two systems are used to define radiation measurements:
• The older system is referred to as the traditional system or standard system.
• The newer system is the metric equivalent known as the SI system.
 1. Exposure
 The term exposure refers to the measurement of ionization in air
produced by X-rays.
• Standard unit: Roentgen (R)
• SI unit: Coulombs per kilogram (C/kg)
•One roentgen is equal to the amount of radiation that produces
approximately two billion, or 2.08 × 10 9 ion pairs in one cubic
centimeter (cc) of air.
2. Dose
 Dose can be defined as the amount of energy absorbed by a tissue.
• Standard unit: Radiation absorbed dose (rad)
• SI unit: Gray (Gy)
•Rad: A special unit of absorbed dose that is equal
to the deposition of 100 ergs of energy per gram of
tissue (100erg/g). [1erg=100 nanojoules]
3. Dose equivalent
 Different types of radiation have different effects on tissues.
 The dose equivalent measurement is used to compare the biological
effects of different types of radiation.
• Standard unit: Roentgen equivalent (in) man (rem)
• SI unit: Sievert (Sv)
4. Radioactivity
• It is the process by which a nucleus of an unstable atom
loses energy by emitting ionizing radiation.
• Standard unit: Curie(Ci)
• SI unit: Becquerel(Bq)
• One Curie is equal to 3.7x1010 (37 Billion Bq)disintegrations per
second.
• One Becquerel is equal to one disintegration per second.
• DPS (disintegrations per second): The number of
subatomic particles (e.g. alpha particles) or photons
(gamma rays) released from the nucleus of a given atom
over one second
Summary of units conversions
• Absorbed dose: the amount of energy deposited by
radiation in a mass. It is expressed in milligrays (mGy)
• The mass can be anything (water, rock, air, people,…)
• Equivalent dose: is calculated for individual organs. It
is based on the absorbed dose to an organ, considering
the radiation type’s effectiveness.
• it is expressed in millisieverts (mSv).
• Effective dose: is calculated for the whole body. It is
the total equivalent doses to all organs, each adjusted
to its sensitivity to radiation.
• it is expressed in millisieverts (mSv).
RADIATION INJURY
RADIATION INJURY
• Radiation injury: tissue damage or changes caused by exposure to
ionizing radiation-namely, gamma and x-rays, such high-energy
particles as neutrons, electrons, and positrons.
• In diagnostic radiography, not all X-rays pass through the patient and
reach the dental x-ray film; some are absorbed by the patient’s tissues.
• Absorption: refers to the total transfer of energy from the x-ray photon to
patient tissues.
•Two mechanisms of radiation injury are possible:
ionization and free radical formation.
Ionisation
• Like other ionizing radiations, when X-rays strike patient
tissues, ionization results.
• Ionization occurs through the photoelectric effect or
Compton scatter and results in the formation of a
positive atom and a dislodged negative electron.
• The ejected high-speed electron is set into motion and
interacts with other atoms within the absorbing tissues.
The kinetic energy of such electrons results in further
ionization, excitation, or breaking of molecular bonds,
all of which cause chemical changes within the cell that
result in biologic damage
Free Radicals Formation
• X-ray causes cell damage primarily through the formation of free
radicals.
• Free radical formation occurs when an x-ray photon ionizes water, the
primary component of living cells.
• Ionization of water results in the production of hydrogen and
hydroxyl free radicals
• A free radical is an uncharged (neutral) atom or molecule that exists
with a single, unpaired electron in its outermost shell.
 Theories of Radiation Injury

• Two theories are used to describe how radiation

damages biological tissues:
• Direct or Target Action Theory
• Indirect Action or Poison Chemical Theory
Theories of Radiation Injury
 Direct or Target Action Theory

• The direct theory of radiation injury suggests that cell damage results
when ionizing radiation directly hits critical areas, or targets, within the
cell.
• For example, if x-ray photons directly strike the DNA of a cell, critical
damage occurs, causing injury to the irradiated organism.
• Direct injuries from exposure to ionizing radiation occur infrequently;
most x-ray photons pass through the cell and cause little or no damage.
 Indirect Action or Poison Chemical Theory

 x-ray photons are absorbed by the water within a cell, and free
radicals are formed. These free radicals combine to form toxins.
(e.g., H 2 O 2 ), which causes cellular dysfunction and biological
damage.
 The chances of free radical formation and indirect injury are great
because cells contain 70% to 80% water.
 Sequence of Radiation Injury

• Chemical reactions (e.g., ionization, free radical formation) that follow the
absorption of radiation occur rapidly at the molecular level.
• However, varying amounts of time are required for these changes to alter cells and
cellular functions.
• As a result, the observable effects of radiation are not visible immediately after
exposure. Instead, following exposure, a latent period occurs.
• A latent period can be defined as the time that elapses between exposure to
ionizing radiation and the appearance of observable clinical signs.
• After the latent period, a period of injury occurs. A variety of cellular injuries may
result, including cell death, changes in cell function, breaking or clumping of
chromosomes, formation of giant cells, cessation of mitotic activity, and abnormal
mitotic activity.
• The last event in the sequence of radiation injury is the recovery period. Not all
cellular radiation injuries are permanent. With each radiation exposure, cellular
damage is followed by repair. Depending on a number of factors, cells can repair the
damage caused by radiation.
• If effects of radiation exposure are additive, the unrepaired damage accumulates in
the tissues. The cumulative effects of repeated radiation exposure can lead to health
problems (e.g., cancer, cataract formation, birth defects).
Radiation Biology Terminologies
• Linear Energy Transfer: Amount of energy is transferred from ionizing radiation
to soft tissue.
• Relative Biologic Effectiveness (RBE): Biologic response compared with two types
of radiation.
• Latent Period: the time lapse between exposure of the radiation and the
appearance of the effects
• Maximum permissible dose: Greatest dose of radiation which is not expected to
cause detectable bodily injury to people at any time during their lifetime.
• For radiology workers this limit for the whole body is 50 mSv, according to ICRP.

• RELATIVE BIOLOGIC
• EFFECTIVENESS(RBE)
• Maximum accumulated dose (MAD): Occupationally
exposed workers must not exceed an accumulated
lifetime radiation dose, and this referred to as MAD.
• MAD is age dependent, MAD=(N-18)x5 rems/ year or
MAD=(N-18)x0.05 Sv/ year. N represents person’s age in
years.
• Minimum required age of a person who works with radiation is
18 years
• Total dose: Quantity of radiation received, or the total
amount of radiation energy absorbed.
• More damage occurs when tissues absorb large quantities of
radiation.
• Dose rate: The amount administered radiation per unit
of time.
• (dose rate = dose/time).
• More radiation damage takes place with high dose rates
because a rapid delivery of radiation does not allow time for
the cellular damage to be repaired.
• When organisms are exposed at lower dose rates, a greater
opportunity exists for repair of damage, thereby resulting in
less net damage.
• Median Lethal dose (LD50): The amount of ionizing radiation
that will kill 50 percent of a population in a specified time.
RBE-LET Curve (Bell-shaped): The RBE-LET curve shows that higher LET
radiation isn't always more biologically effective.

• At higher LETs, some of the energy is wasted because more ionization

events than needed occur in the same area. This is known as the "overkill
effect.
TYPES OF RADIATION EFFECTS
Stochastic effects
• Stochastic effects are those that may develop, and their
development is random and depends on the laws of chance or
probability.
• Examples of somatic stochastic effects include leukaemia and certain tumours.
• These damaging effects may be induced when the body is exposed to any dose
of radiation.
• Experimentally it has not been possible to establish a safe dose, below which
stochastic effects do not develop.
• Therefore, there is no threshold dose. every exposure to ionizing radiation
carries with the possibility of inducing a stochastic effect.
• However, the severity of the damage is not related to the size of the inducing
dose.
• This is the underlying philosophy behind present radiation protection
recommendations.
Deterministic effects
• Nonstochastic effects (deterministic effects) are
somatic effects that have a threshold and that increase
in severity with increasing absorbed dose.
• Examples of non-stochastic effects include erythema, loss of
hair, cataract formation, and decreased fertility.
• Compared with stochastic effects, deterministic effects require
larger radiation doses to cause serious impairment of health.
Short term effects
• Following the latent period, effects that are seen within
minutes, days, or weeks are termed short-term effects.
• Short-term effects are associated with large amounts of
radiation absorbed in a short time (e.g., exposure to a
nuclear accident or the atomic bomb).
• Acute radiation syndrome (ARS) is a short-term effect
and includes nausea, vomiting, diarrhea, hair loss, and
hemorrhage.
• Short-term effects are not applicable to dentistry.
Long term effects
• Effects that appear after years, decades, or generations
are termed long-term effects.
• Long-term effects are associated with small amounts of
radiation absorbed repeatedly over a long period.
• Repeated low levels of radiation exposure are linked to
the induction of cancer, birth abnormalities, and genetic
defects.
Somatic and Genetic Effects
• All the cells in the body can be classified as either
somatic or genetic.
• Somatic cells are all the cells in the body except the
reproductive cells.
• The reproductive cells (e.g., ova, sperm) are termed
genetic cells.
• Depending on the type of cell injured by radiation, the
biologic effects of radiation can be classified as somatic
or genetic.
Somatic effects
• Somatic effects are seen in the person who has been
irradiated. Radiation injuries that produce changes in
somatic cells produce poor health in the irradiated
individual.
• Major somatic effects of radiation exposure include the
induction of cancer, leukemia, and cataracts.
• These changes, however, are not transmitted to future
generations
Genetic effects
• Genetic effects are not seen in the irradiated person but are
passed on to future generations.
• Radiation injuries that produce changes in genetic cells do not
affect the health of the exposed individual.
• Instead, the radiation-induced mutations affect the health of the
offspring .
• Genetic damage cannot be repaired.
• Doubling dose: dose of radiation expected to double the number
of genetic mutations in a generation.
• Or Amount of radiation that doubles the incidence of stochastic effects.
• Human data from Hiroshima/Nagasaki suggest somewhat average
doubling dose is 1.6 Sv
Effects on the unborn child
• The developing fetus is particularly sensitive to the effects of
radiation, especially during the period of organogenesis (2–9 weeks
after conception).
• Exposures in the range of 2 to 3 Gy during the first few days after
conception are thought to cause undetectable death of the embryo.
• The period of maximal sensitivity of the brain is 8 to 15 weeks after
conception.
• The major problems are:
• Congenital abnormalities or death associated with large doses of radiation
• Mental retardation associated with low doses of radiation.
• As a result, the maximum permissible dose to the abdomen of a
woman who is pregnant is regulated by law.
Factors determining biological
effects of radiation
• Nature of tissue irradiated: Radioresponsive vs Radioresistant.
• Area irradiated: For the same dose, if a smaller area is irradiated,
the effect of radiation is less.
• Rate of dose: Smaller the dose, distributed over a large period of
time results in a smaller or lesser effect of the radiation.
• Fractionization: Division of the dose, with sufficient gaps, helps
in tissue recovery resulting in lesser effect of the radiation.
• Latent period: This is the period between the time of irradiation
and the appearance of the effect.
• Age of the patient: Younger the patient greater the chances of
recovery.
Factors determining biological
effects of radiation
• Recovery power of the tissue: Undifferentiated cells have a
greater power of recovery.
• Type of cell: The effect of radiation is seen in the same
generation if a somatic cell is affected, and in case of the
genetic cell the effect of radiation will be seen in the next
generation.
• Type of irradiation: There are different types of irradiations—
low energy, high energy or linear energy transfer.
• Stage of development of the tissue: The effect of
irradiation depends on the stage of development of the tissue,
• e.g. primitive and undifferentiated and still undergoing mitosis when
irradiated the damage caused is greater.
• Tissue threshold: Greater the tissue threshold,lesser the damage seen. This
depends on the amount of radiation absorbed. Somatic changes do not occur
until a minimum of tissue threshold is exceeded. Genetic changes occur with
any given dose.
• Species and individuals: Different species respond differently. The median
lethal dose varies in different species. Similarly in individuals of the same
species the response may be variable.
• Oxygenation: Greater oxygenation of the tissue, chances of recovery are
greater, e.g. hyperbaric oxygen is used to treat osteoradio necrosis.
• The presence of oxygen in a cell acts as a radiosensitizer, making the effects of the
radiation more damaging. Tumor cells typically have a lower oxygen content than
normal tissue.
• This medical condition is known as tumor hypoxia and therefore the oxygen effect acts
to decrease the sensitivity of tumor tissue. Generally it is believed that neutron
irradiation overcomes the effect of tumor hypoxia, although there are
counterarguments.
BIOLOGICAL EFFECTS (ON CELLS, CRITICAL ORGANS,
WHOLE BODY)
BIOLOGICAL EFFECTS OF RADIATION
ON CELLS
1. Biological effects of radiation on
DNA
Direct vs indirect damage to DNA
Types of radiation-induced DNA
damage
• Single strand break: can repair
• Double strand break is responsible for
• Mutation
• Cell death
• Carcinogenisis
• Point mutations: Effect of radiation on individual genes
Biological effects of radiation on
cytoplasm and nucleus
• Increased permeability of plasma membrane to sodium
and potassium ions.
• Swelling and disorganization of mitochondria.
• Focal cytoplasmic necrosis.
• Nucleus is more radiosensitive than cytoplasm
Biological effects of radiation on
proteins
• Denaturation.
• Primary structure of the protein is usually not
significantly altered
• Secondary and tertiary structures are affected by
breakage of hydrogen or disulfide bonds
• Inactivation of enzymes sometimes occurs.
Biological effects of radiation on
mitochondria
• Mitochondria demonstrate –
• Increased permeability
• Swelling
• Disorganization of the internal cristae
Biological effects of radiation on
chromosomes (during cell cycle)
• Chromosomal aberrations:
• If radiation exposure occurs after DNA synthesis (i,e G2 or
later)only one arm of the affected chromosome is broken
• If radiation occurs before DNA synthesis (G1 or early S) both
arms are affected

• The survivors of the atomic bombings of Hiroshima and

Nagasaki have demonstrated chromosome aberrations in
circulating lymphocytes more than two decades after the
radiation exposure.
Examples of mutations
Biological effects on cell replication
• Mild dose-mild mitotic delay
• Moderate dose-longer mitotic delay
• Severe dose-profound delay with incomplete recovery
Cell Death
• Reproductive death in a cell population is loss of the
capacity for
mitotic division.
• The three mechanisms of reproductive death are
• DNA damage (single strand break or two strand break)
• Bystander effect
• Apoptosis.
• Bystander effect: It is the phenomenon in which
unirradiated(normal) cells exhibit irradiated effects as a result of
signals received from nearby irradiated cells.
• This bystander effect has been demonstrated for both α
particles and x rays and causes chromosome aberrations, cell
killing, gene mutations, and carcinogenesis.
• The abscopal effect is a phenomenon where the response to
radiation is seen in an area distant to the irradiated area, that is,
the responding cells are not juxtaposed(close) with the
irradiated cells.
• T cells and dendritic cells have been implicated to be part of the
mechanism.
• In suicide gene therapy, the "bystander effect" is the ability
of the transfected cells to transfer death signals to neighboring
tumor cells.
Apoptosis
• Leaves falling from tree
• Also known as’ programmed cell death’
• Apoptosis is particularly common in hemopoietic and
lymphoid tissues.
RADIATION EFFECTS ON CRITICAL
ORGANS
• In dental radiography the critical organs receiving
scattered radiation include:
• SKIN
• BONE MARROW
• THYROID
• GONADAL
• EYE
Skin
• The reaction of the skin to radiation may be categorized
as:
• Early or acute signs:
• Increased susceptibility to chapping.
• Intolerance to surgical scrub.
• Blunting and leveling of finger ridges.
• Brittleness and ridging of fingernails.
• Late or chronic signs:
• Loosening of hair and epilation.
• Dryness and atrophy of skin, due to destruction of the sweat glands.
• Progressive pigmentation, telangiectasis and keratosis.
• Indolent type of ulcerations.
• Possibility of malignant changes in tissue.
• All these changes in the skin are due to radiation
trauma to:
• The blood vessels.
• Connective tissue.
• Epithelium.
• Early erythema may appear from a single dose of about
450 rads.
• With lower doses no erythema occurs.
Bonne marrow
• 13 mR for full mouth intraoral periapical radiographs.
• A maximum dose of 200 R is required for any damage to the
marrow or blood forming organs.
• Hence, the risk of bone marrow damage from dental X-
rays is small.
• The primary somatic risk from dental radiography is
leukemia induction, especially in young individuals.
• This is because at birth all bones contain only red bone
marrow.
Other organs
• Thyroid
• 40 mR for full mouth intraoral periapical radiographs.
• A dose of 10 R will produce thyroid cancer.
• Gonadal: a single intraoral radiograph gives 100 to 900
mR to the face.
• From this; Male gonads receive 0.3 mR.
• Female gonads receive 0.03 to 0.001 mR,
• Eye: a series of full mouth intraoral periapical
radiographs, will give only a few mR.
• Cataract of the lens is produced after 500 R of exposure.
RADIATION EFFECT ON ORAL
TISSUES
• ORAL MUCOUS MEBRANE
• TASTE BUDS
• SALIVARY GLANDS
• RADIATION CARIES
• OSTEORADIO NECROSIS
• Oral mucosal membrane
• Pre-radiation Therapy Management Considerations:
• A complete dental examination to identify preexisting problems.
• Prior to treatment, potentially complicating diseases should be
corrected
• Patient adherence to hygiene protocols are critical
Mucositis
• The inflammation of oral mucosa resulting from chemotherapeutic
agents or ionizing radiation.
• Typically manifests as erythema or ulcerations.
• May be exacerbated by local factors.
• Dysgeusia, or an alteration in taste perception
• Red,shiny, or awollen mouth and gums
• Blood in the mouth
• Sores in mouth,gums and tongue
• Difficulty swallowing or talking
• Soft, whitish patches in the mouth and tongue
• Increased mucous or thicker saliva
Pathophysiology of mucositis
• The pathophysiology of mucositis can be divided into 5
stages:
• Initiation phase
• Message generation phase
• Signaling and amplification phase
• Ulceration phase
• Healing phase
 Management of
mucositis

• Good oral hygiene.

• Avoidance of spicy, acidic, hard, and hot foods and
beverages.
• Use of mild-flavored toothpastes.
• Use of saline-peroxide mouthwashes 3 or 4 times
per day.
• Bland rinses:
– 0.9% saline solution.
– Sodium bicarbonate solution.
• Topical anesthetics:
– Lidocaine: viscous, ointments, Sprays.
– Benzocaine: sprays, gels.
– 0.5% or 1.0% dyclonine hydrochloride (HCl).
– Diphenhydramine solution.
• Mucosal coating agents:
– Amphojel.
– Kaopectate.
– Hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin).
– Gelclair-Bioadherent (approved by the U.S. Food and Drug
Administration [FDA]
• Analgesics:
– Benzydamine HCl topical rinse
– Opioid drugs: oral, intravenous (e.g., bolus, continuous infusion,
patient-controlled analgesia [PCA]), patches, transmucosal.
 Radiation effects on taste buds
• Taste buds are sensitive to radiation and patient realizes a
loss of taste in the second or third week of radiation
therapy.
• Radiation directed to the mouth will affect taste buds
located on the tongue.
• The tongue's lining and taste buds are susceptible to
radiation. A decrease in saliva also causes changes in taste.
• It is common to have an increased sensitivity to sour and
bitter taste,or to have a “metallic” taste in your mouth
• Changes in taste may cause you to lose your appetite.
 Management of taste loss

• At this time, there is no treatment for taste

changes.
• Research has shown that taking zinc sulfate during
treatment may be helpful in expediting the return
of taste after head and neck irradiation.
 Radiation effects on salivary glands
• Parotid gland is more radio sensitive than the other glands
• Increase the growth of st.mutans,lactobacillous,candida
• Decrease the ph leads to decalcification of enamel
• Difficult to swallow(DYSPHAGIA)
• Decrease salivary secretion(XEROSTOMIA)
• The parenchymal component of the gland is sensitive to
radiation.
• The gland demonstrates progressive fibrosis adiposis, loss of fine
vasculature and simultaneous parenchymal degeneration.
• There is marked decrease in the salivary flow.
• The composition of saliva is affected.
•There is increased concentration of sodium,chloride, calcium,
magnesium ions and proteins.
• The saliva loses its lubricating properties.
• The mouth becomes dry and tender due to xerostomia.
•The pH of saliva is decreased which may initiate
decalcification of enamel.
•A compensatory hypertrophy of the salivary gland may take place and
the xerostomia may subside after six to twelve months after therapy.
Advancements in radiotherapy to
minimise radiation effects
• Accelerated hyper fractionated radiation therapy:
In this approach, radiation is given twice a day over a
shorter total length of time.
• Three-dimensional conformal radiation therapy
(3D-CRT): 3D- CRT uses the results of imaging tests
such as MRI and special computers to precisely map the
location of the tumor.
• Several radiation beams are then shaped and aimed at the
tumor from different directions.
• Each beam alone is fairly weak, which makes it less likely to
damage normal tissues, but the beams converge at the tumor
to give a higher dose of radiation there.
• Intensity modulated radiation therapy (IMRT): It uses a
computer-driven machine that actually moves around the patient as
it delivers radiation.
• In addition to shaping the beams and aiming them at the tumor from
several angles, the intensity (strength) of the beams can be adjusted to
limit the dose reaching the most sensitive nearby normal tissues.
• Many major hospitals and cancer centers now use IMRT as the standard way
to deliver external beam radiation.
• Fast neutron beam radiation: Instead of using x-rays, neutron
radiation therapy uses a beam of high-energy neutrons.
• It was suggested that this type of radiation may be more effective, but it
may also lead to more side effects.
• Neutron therapy machines are currently available in only few cancer
centers in the United States.
• A neutron radiotherapy facility would probably cost $20 to
$25 million dollars today.
• Neutron therapy is especially good at controlling salivary gland
cancer at the tumor site and in the same region.
• Neutron therapy also works best on tumors below 4
centimeters in diameter
• But it is used with success on many larger tumors as well.
Radiation effects on teeth (radiation
caries)
• Evidence in changes of crystalline structure of enamel, dentin,
or cementum following RT is unclear.
• Pulp shows decrease in vascular elements, with
accompanying fibrosis and atrophy.
• Pulpal response to infection, trauma, and various dental
procedures appears compromised.
• Radiation level as low as 2500 cGy can have marked effect on
tooth development.
• Exposure before calcification completion - tooth bud may be
damaged
• At later stage of development - may arrest growth.
• Children receiving radiation therapy to the jaws may show
defects in the permanent dentition such as retarded root
development, dwarfed teeth, or failure to form one or more
teeth
• If exposure precedes calcification, irradiation may destroy the
tooth bud. Irradiation after calcification has begun may inhibit
cellular differentiation,causing malformations and arresting
general growth.
• Eruptive mechanism of teeth is relatively radiation resistant
• Adult teeth are resistant to the direct effects of radiation
exposure.
• Radiation has no direct effect on the crystalline structure of
enamel, dentin, or cementum, and radiation does not increase
their solubility.
RADIATION
CARIES
• Radiation caries is a rampant form of dental decay that may
occur in individuals who receive a course of radiotherapy
that includes exposure of the salivary glands.
• Patients receiving radiation therapy to oral structures have
increases in Streptococcus mutans,Lactobacillus, and
Candida .
• Caries results from changes in the salivary glands and
saliva, including reduced flow, decreased pH, reduced
buffering capacity, increased viscosity, and altered flora.
 Types of radiation caries
• Clinically, three types of radiation caries exist.
1. The most common is widespread superficial lesions
attacking buccal, occlusal, incisal, and palatal surfaces.
2. Another type involves primarily the cementum and dentin
in the cervical region. These lesions may progress around the
teeth circumferentially and result in loss of the crown.
3. A final type appears as a dark pigmentation of the
entire crown. The incisal edges may be markedly worn.
Combinations of all these lesions develop in some patients
PREVENTION AND MANAGEMENT

• Although radiation caries is a multifactorial condition, its

main risk factor in HNC patients is radiation treatment-
induced reduction of salivary flow.
• Exclusion of the major and minor salivary glands from the
irradiation field.
• Intensity-modulated radiotherapy (IMRT) and Three-
dimensional conformal radiation therapy (3D-CRT): techniques will
be of great benefit to patients.
• There are also artificial salivas (saliva substitutes)
capable of increasing tissue lubrication, hydration,
salivary clearance, and pH neutralization.
• Pilocarpine(pilomax)-5mg,3 times a day for 12
weeks.
• Cevimeline(Evoxac)-30mg,3 times a day for 12
weeks.
 Qualitative improvement
• 1% neutral sodium fluoride gel applied daily in
custom trays could significantly reduce caries in
irradiated patients.
• combination of fluoride and chlorhexidine used
daily has been shown to offer better results
for patients with a high risk of developing
radiation caries.
• Composite and glass-ionomer fillings.
 OSTEORADIONECROSIS
DEFINITION;
 An exposure of irradiated bone which fails to heal with out
intervention (Marx 1983)
 It is a chronic nonhealing wound caused by hypoxia,
hypocellularity, and hypovascularity (3H)of irradiated
tissue (Marx and Johnson 1987)
INCIDENCE
• Mandible is affected more commonly; because most oral
tumors are peri mandibular.
• More extensive blood supply in maxilla, reduce
incidences
• Incidence 8.2%
• 3 fold higher in Men
• Body of mandible
• Combined radio and chemo
 Etiology (3Hs)
 Radiation in excess of 50Gy- kills bone cells – osteoblasts &
fibroblasts leading to hypocellularity
 Vessels -tunica intima endarteritis,
periarteritis hyalinization and fibrosis
 Progressive obliterative arteritis.—hypovascularity
Periosteal vessels and inferior alveolar artery involved
 Hypoxia
 Effects of radiation on bone
• Depletion of osteoblasts - Increased
osteoclastic resorption of bone
Reduced bone rebuilding potential
+
• Progressive endarteritis - reduction of blood
flow through the Haversian and Volkmann’s
canals
=
OSTEOPOROSIS

OSTEONECROSIS
CLASSIFICATION OF
OSTEORADIONECROSIS
• By Marx(1983)
Type I – Develops shortly after radiation, Due
to synergistic effects of surgical
trauma and radiation injury.

Type II – Develops years after radiation and follows a trauma

Rarely occurs before 2 year after treatment &
commonly occurs after 6 years.
Due to progressive endarteritis and vascular effusion.
Type III
Occurs spontaneously without a preceding a traumatic
event.
Usually occurs between 6 months and 3 years after radiation.
Due to immediate cellular damage and death due to radiation
treatment.
BIOLOGICAL EFFECTS OF RADIATION
ON WHOLE BODY
EFFECTS IN WHOLE BODY

•ACUTE RADIATION SYNDROME

•HEMATOPOITIC SYNDROME
•GASTROINTESTINAL SYNDROME
•CARDIOVASCULAR SYNDROME
•CENTRAL NERVOUS SYSTEM SYNDROME

158
 ACUTE RADIATION SYNDROME
 Acute Radiation Syndrome (ARS) is an acute illness
caused by irradiation of the entire body (or most of the
body) by a high dose of penetrating radiation in a very
short period of
time (usually a matter of minutes)
 stages of ARS

Prodromal stage (N-V-D stage): The classic symptoms for this stage are
nausea, vomiting, as well as anorexia and possibly diarrhea (depending
on dose), which occur from minutes to days following exposure. The
symptoms may last (episodically) for minutes up to several days.
Latent stage: In this stage, the patient looks and feels generally
healthy for a few hours or even up to a few weeks.
Manifest illness stage: In this stage the symptoms depend on the
specific syndrome and last from hours up to several months.
Recovery or death: Most patients who do not recover will die within
several months of exposure. The recovery process lasts from several
weeks up to two years
Bone marrow (hemopoietic) syndrome:

• (2 to7 Gy) Here severe damage may be caused to the

circulatory system.
• The bone marrow being radiosensitive, results in fall in the
number of granulocytes, platelets and erythrocytes.
• Clinically this is manifested as lymphopenia,
granulocytopenia and hemorrhage due to
thrombocytopenia and anemia due to depletion of the
erythrocytes.
 Gastrointestinal syndrome
• (7 to 15 Gy): This causes extensive damage to the
gastrointestinal tract, leading to anorexia,
nausea, vomiting,severe diarrhea and
malaise.
Cardiovascular and central nervous system
syndrome
• More than 50 Gy
• This produces death within one or two days. Individuals
show incordination,disorientation and convulsions
suggestive of extensive damage to the nervous system.
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References
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