Dental Oncology · Pre-Radiation Care
If you or someone you love is scheduled for radiation therapy to the head or neck, your oncology team may have already asked you to see a dentist first, ideally one close to where you're already receiving care. Here is what osteoradionecrosis is, why certain teeth are removed before radiation begins rather than after, and how Dr. Debbie Lee plans around it as a fellowship-trained dental oncologist.
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Teeth with severe periodontal disease are usually removed before head and neck radiation begins, not afterward. Radiation reduces the jaw bone's ability to heal, so extracting a problem tooth once treatment is already underway carries a real risk of osteoradionecrosis (ORN) — a serious complication in which the bone becomes necrotic and fails to heal. Dr. Debbie Lee evaluates this during pre-treatment dental clearance, working from the dental oncology training she completed at Memorial Sloan Kettering.
Osteoradionecrosis doesn't come up in most dental conversations, which is part of why it catches patients off guard. It's specific to what radiation does to bone in the treated area, and it's the reason a dental evaluation before radiation isn't just a formality.
When ORN does develop, treatment options are limited and difficult. It can often lead to hyperbaric oxygen therapy — an expensive, time-consuming treatment that, in Dr. Lee's clinical experience, is frequently not successful. That gap between how serious ORN can be and how hard it can be to treat once it starts is exactly why prevention, through a dental evaluation before radiation begins, is emphasized so strongly.
Not every tooth needs attention before radiation. Dr. Lee's evaluation is about identifying the specific teeth that are unlikely to hold up over time and pose the greatest risk if they're left in place once treatment begins — it isn't a blanket recommendation to remove every tooth with any sign of gum disease, but a targeted, tooth-by-tooth decision.
Periodontal disease severity
Teeth affected by severe periodontal disease are the primary concern. These are the teeth most likely to need extraction, since leaving them in place raises the risk of osteoradionecrosis once radiation is underway — teeth with mild or well-managed gum disease typically don't need to be addressed this way.
Imaging of the jaw
Dr. Lee examines the bone supporting each tooth using in-office CBCT imaging and low-dose digital x-rays, giving a fuller picture of the tooth and the bone around it than a visual exam alone could provide.
Restorative outlook
For any tooth that does need to come out, Dr. Lee is already thinking about how it will be restored or replaced, so a patient isn't left facing a gap in their smile with no plan for what comes next.
The distinction between "before" and "after" matters because of what radiation does to the jaw bone.
Extraction before radiation
The bone can still heal the way it normally would, so removing a problem tooth ahead of treatment avoids putting the jaw through an extraction once that capacity has changed.
Extraction after radiation
Radiation affects blood supply to the jaw, so an extraction from that same bone afterward carries the risk described above — that it won't heal normally.
This is why Dr. Lee's evaluation happens on the front end of a patient's cancer treatment plan, coordinated with the oncology team's own timeline, rather than waiting to see which teeth become a problem later. It also means there's a real deadline involved: any extraction has to happen with enough time built in beforehand for the site to heal before radiation begins, not squeezed in right before the first treatment appointment.
None of this means every patient facing head and neck radiation needs multiple extractions. Many patients need none at all, and for those who do, the evaluation itself is straightforward. But for the teeth that do need to come out, the timing isn't as flexible as it might be for a routine extraction — it has to happen early enough in treatment planning for healing to finish before radiation starts.
Removing a tooth is never the end of the conversation for Dr. Lee. As a dental oncologist, she also has keen knowledge of how to restore teeth from a restorative and prosthetic standpoint, so that side of the plan is considered alongside the extraction itself rather than figured out later. Patients who want to understand that part of care in more depth can read more about Manhattan Oral Health's approach to restorative dentistry.
This approach comes directly from Dr. Lee's dental oncology fellowship at Memorial Sloan Kettering (MSK), where she routinely performed pre-treatment dental clearance for head and neck cancer patients ahead of their radiation therapy. That training built on three additional years in a hospital setting — a general practice residency, an anesthesia fellowship, and oncology training — on top of 32 years of clinical experience, background she draws on any time a patient's dental care has to be coordinated closely with a broader cancer treatment plan.
It also reflects a broader approach Dr. Lee brings to dental oncology care: treating the whole patient, not just the tooth in front of her. Her training sits at the intersection of dentistry and medicine, so a patient's cancer treatment plan, not just their dental history, shapes how she approaches a case like this one. Coordinating care this closely with a radiation timeline is also part of why Manhattan Oral Health operates as a boutique practice, with a treatment plan built around what a patient's medical situation actually calls for rather than around insurance coverage alone.
Manhattan Oral Health's dental oncology care covers this kind of coordination more broadly. If you're earlier in your cancer treatment planning, or your care involves chemotherapy, surgery, or stem cell treatment in addition to or instead of radiation, our guide to dental care before cancer treatment covers the broader picture of pre-treatment dental clearance.
This page is general information for patients preparing for head and neck radiation. It isn't a substitute for evaluation by your oncology and dental care team.
If radiation to the head or neck is part of your treatment plan, reach out to set up a pre-treatment dental evaluation with Dr. Lee before your first appointment.
Contact Dr. Lee's Office →Osteoradionecrosis, or ORN, is a severe complication of radiation therapy to the head and neck in which the jaw bone becomes necrotic and fails to heal. It's one of the main reasons dental evaluation happens before radiation begins rather than after.
Extracting a tooth from bone that has already been irradiated carries a real risk of osteoradionecrosis, since that bone has a reduced ability to heal. Removing a problem tooth beforehand, while the bone can still heal normally, avoids putting the jaw through that risk once treatment is underway.
Teeth affected by severe periodontal disease are the primary concern. Dr. Lee evaluates each tooth's condition, including imaging of the supporting bone with in-office CBCT and low-dose digital x-rays, to determine which teeth are unlikely to hold up long-term and should come out before treatment starts.
Treating ORN can require hyperbaric oxygen therapy, a costly and time-intensive treatment that, in Dr. Lee's clinical experience, is often not successful. That's the main reason prevention through a pre-radiation dental evaluation matters so much.
Yes. As a dental oncologist, Dr. Lee thinks through the restorative and prosthetic side of a case at the same time as the extraction itself, not as a separate decision made later.
Radiation to the head and neck can increase a patient's risk of aspiration and difficulty swallowing. Dr. Lee stays aware of this during dental treatment, since aspiration can lead to pulmonary infection, and takes it into account when planning and performing care.
As soon as radiation becomes part of the treatment conversation. There's no single fixed timeline, since it depends on your oncology team's schedule and how many teeth need attention, but earlier is better — it leaves enough time for any needed extractions to heal fully before your first radiation appointment.