Journal of Conservative Dentistry

: 2022  |  Volume : 25  |  Issue : 5  |  Page : 481--486

Indices for the assessment of radiation-related caries

Aakanksha Chopra1, Nitika Monga2, Sidhartha Sharma1, Vijay Kumar1, Amrita Chawla1, Ajay Logani1,  
1 Division of Conservative Dentistry and Endodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 Non- Communicable Disease Division, Indian Council of Medical Research, New Delhi, India

Correspondence Address:
Dr. Vijay Kumar
Room Number. 308, Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi - 110029


Radiation therapy, either used alone or in combination with surgery and or chemotherapy, is the most commonly utilized modality for treating head and neck cancers. Patients undergoing radiation therapy usually experience significant early and late-onset toxicities/adverse effects. Radiation-related caries (RRC) is a common complication that detrimentally affects patients' quality of life (QoL). A clearer understanding and more uniform approach to scoring systems help provide a more accurate diagnosis, form treatment protocols, plan, and evaluate outcomes of preventive initiatives and create scientific databases. Many indices have been used to assess and quantify the dental caries experience after radiotherapy. Considering the need for uniform standards for measuring radiation caries, indices specific to radiation caries have been proposed in the literature to capture postradiation damage to the dentition accurately. This narrative review aims to consolidate the evolution of different indices used for scoring RRC to improve the understanding of radiation caries assessment.

How to cite this article:
Chopra A, Monga N, Sharma S, Kumar V, Chawla A, Logani A. Indices for the assessment of radiation-related caries.J Conserv Dent 2022;25:481-486

How to cite this URL:
Chopra A, Monga N, Sharma S, Kumar V, Chawla A, Logani A. Indices for the assessment of radiation-related caries. J Conserv Dent [serial online] 2022 [cited 2022 Sep 25 ];25:481-486
Available from:

Full Text


Cancers of the head and neck region are the sixth most common form of cancer worldwide and rank among the top three types in India.[1],[2] This condition often requires a multidisciplinary approach. Depending on the presentation stage, radiotherapy (RT) alone or in combination with surgery or chemotherapy is used as a significant treatment modality.[3] RT involves the use of ionizing radiation to target cancerous cells. However, the normal tissues in the zone of radiation therapy are inadvertently affected. The plausibility and severity of radiation-related adverse effects are multifactorial and depend on the site, extent of the tumor, total radiation dose, and precision of the radiation machine. Complication rates are higher in patients with concurrent chemotherapy and preexisting systemic diseases such as diabetes, cardiovascular conditions, and neurological problems.

The adverse effects of RT can be categorized as early and late onset.[4] Early or acute side effects occur during and immediately (approximately 2–3 weeks) after completing a course of radiation therapy. These include mucositis, loss of taste or altered taste sensation, candidiasis, dermatitis of irradiated skin, odynophagia, laryngeal edema accompanied by hoarseness of voice. Late effects can manifest at any time thereafter, from weeks to years later, and have profound, long-lasting consequences on the QoL. These include xerostomia, trismus, carious breakdown of dentition, and osteoradionecrosis.

Radiation-related caries (RRC) is well-documented and one of the most common complications, affecting approximately 25% of patients after HNRT.[5] RRC has a rapid onset, quick progression and is an essentially destructive form of dental decay. This can lead to persistent infection, pain, and an increased risk of the development of osteoradionecrosis. RRC generally occurs between 6 and 12 months after the conclusion of HNRT.

RRC manifests a characteristic clinical course that starts as discrete enamel cracks and fractures and progresses to brown or blackish discoloration of the enamel. Due to its presentation as a cervical, annular lesions typically involving more than one surface RRC are also referred to as the “caries circularis.”[6] If not treated promptly, RRC can rapidly progress to the underlying dentin and cause complete amputation of the tooth crown. RRC is distinguished from ordinary smooth surface dental caries by its characteristic involvement of areas of teeth that are often resistant to decay (lingual surfaces of incisors and premolars, incisal edges, and cusp tips), rapid progression, and absence of acute pain in even advanced lesions.

The etiopathogenesis of RRC is considered multifactorial. It is primarily attributed to indirect effects of radiation therapy. Salivary glands undergo dose-dependent degenerative changes after radiation therapy. Radiation-induced salivary gland damage primarily affects the serous cells, with minor effects on the mucous cells and ductal epithelium. Changes in salivary production begin within the 1st week of radiation therapy for doses around 20 Gray (Gy). Salivary secretions decrease up to 50% at 4–5 fractions The decreased salivary flow rate leads to thick and ropey saliva with low pH and reduced buffering capacity.[7],[8] Oral saliva pH 5.3 increases the risk for RRCs, and patients with low pH for a long time recover slowly.[9] With impaired oral clearance and compromised oral hygiene due to mucositis, trismus, and oral discomfort, acidogenic and cariogenic bacteria such as Streptococcus mutans, Lactobacillus, and Candida species tend to grow.[10],[11],[12] All these things manifest as “clustering of oral symptoms,” leading to the development of a conducive environment for dental caries.[13] Besides indirect damage, radiation caries is also a product of direct radiation-induced effects on dental hard tissues.[14] The damage to the mineralized structure of the tooth is minimal at doses <30 Gy (salivary gland threshold) but the damage increases two to three folds for radiation doses between 30 and 60 Gy.[15],[16],[17] These are reflected in the reduction of microhardness and modulus of elasticity of enamel near DEJ, destabilization of DEJ, decreased crystallinity and loss of mineral and protein content in both enamel and dentin.[14],[15]

Studies on the impact of radiation therapy on dental development reported that at therapeutic radiation doses in children in addition to salivary gland dysfunction, the formation of “osteodentin” is observed due to the interference with the mitotic activity of the rapidly dividing preodontoblasts, resulting in impaired nucleation of enamel following mineralization.[18],[19] The odontogenic cells in performative and differentiative phases are more sensitive to radiation than cells in the secretory or maturation stage. Exposure to radiation before calcification leads to the destruction of tooth bud, while exposure at later stages results in defective enamel and dentin formation with shortened roots.[20],[21] The age-related changes in dentine and the exposure of root surface due to gingival recession increases the risk of RRC in the elderly. However, irrespective of age, the alteration in composition and mechanical changes in the tooth structures makes the restoration of RRC a daunting task for dentists. A study on the clinical performance of different restorative materials reported that conventional glass ionomer cement (GIC) appears to show better sealing ability, while composite resin presented better long-term integrity and marginal adaptation. Based on the findings, it is suggested to use convention GIC as a base under composite resin.[22]

The detrimental effect of RRC on the QoL of head and neck cancer patients has been well accepted and documented.[23] Epidemiological investigations require accurate measurement and quantification of the disease to study its burden. A clearer understanding and more uniform approach to scoring systems help provide a more accurate diagnosis, treatment protocols, forming a scientific database, planning, and evaluating outcomes of preventive initiatives taken. Many indices have been used to assess and quantify the dental caries experience after RT. Considering the need for uniform standards for measuring radiation, caries-specific indices have been proposed in the literature to accurately capture post-radiation damage to the dentition. This narrative review consolidates the evolution of different indices used for scoring RRCs.

 Nonspecific Dental Caries Indices Used To Measure Radiation-Related Caries

The Decayed Missing Filled Teeth (DMFT) and Decayed, Missing, filled surface (DMFS) indices were developed by Henry Klein, Palmer, and Knutson in 1938 to determine the prevalence of coronal caries.[24] Both DMFT and DMFS require evaluation of 28 permanent teeth, excluding retained primary teeth and third molars. If the occlusal surface of a tooth is exposed or may be exposed by the manual reflection of the gingiva, it is considered to have erupted. The DMFS requires the evaluation of four surfaces (buccal, palatal, mesial, and distal) in anterior teeth and five surfaces (buccal, lingual, mesial, distal, and occlusal) in posterior teeth. No tooth or surface is counted more than once, and missing is only reported for teeth or surfaces lost attributable to caries. Congenitally missing or unerupted teeth and teeth lost due to traumatic dental injury are excluded. Restorations due to reasons other than caries (e.g., hypoplastic teeth, abutments, and preventive fissure sealants) are also excluded from evaluation.

Initially used to describe the dental status and treatment need in preelementary school children, DMFT and DMFS soon became a tool to describe caries experience in epidemiologic studies due to its simplicity, ease of performance, and versatility. However, these indices lacked discrete differentiation between diseased state or treated condition and arrested carious lesion thus can overestimate caries experience in teeth with preventive restorations. In addition, they lose validity in population groups such as the elderly, people with motor difficulties, and others who may lose teeth for reasons other than caries. When used for the evaluation of RRC, the use of DMFT and DMFS underestimates the degree of RRC due to failure to capture incisal edge caries.

The international caries detection and assessment system (ICDAS) was developed by a team of researchers, epidemiologists, and restorative dentists with their first meeting held in 2002, integrating several criteria and combining evidence received from various studies into one standard system of caries detection and assessment.[25] ICDAS estimates changes on the surface and potential histological depth of carious lesions by relying on surface characteristics. It detects six stages of the carious process ranging from early visible changes in enamel to extensive distinct cavitation.[25] The index includes two components: The 'D' stands for detection of dental caries by stage of the carious process, the topography of lesion (pit and fissures or smooth surfaces), anatomy (crown or root status), and restoration or sealant. Component 'A' stands for assessment by analyzing whether the carious lesion is cavitated or non cavitated and active or arrested caries. The major shortcoming was that in the initial ICDAS criteria, detection and assessment of only coronal carious lesion activity and radicular caries were not included. In 2005, the IACDS coordination committee modified the initial assessment criteria to include caries associated with sealants and root caries along with coronal caries, and the ICDAS II system [Table 1] was developed.[26],[27],[28] The principal advantage of ICDAS is the ability to evaluate noncavitated lesions. Braga et al. evaluated the feasibility of using ICDAS II criteria in an epidemiological survey to assess its correlation with the WHO criteria.[29] WHO criteria classify tooth surfaces as sound, decayed, filled, or indicated for extraction.[30] They observed that ICDAS II took twice as long the application time when compared with WHO criteria. It may lead to an overestimation of the seriousness of dental caries experience.[17] and requires a longer application time when compared with WHO criteria.[15],[18],[19] When used for assessment of RRC, it underestimates the degree of RRC due to a failure to capture incisal edge and cusp tip decay, enamel delamination, and crown amputation.{Table 1}

 Specific Indices for the Measurement of the Radiation-Related Caries

Post-radiation dental index

Walker et al. in 2008, developed the post-radiation dental index (PRDI) as a measure to assess the pattern and severity of lost tooth structure after radiation therapy.[31] It was the first caries index designed specifically to assess RRC. Each tooth crown is divided into three surfaces (buccal, lingual, and occlusal for posterior teeth) or two surfaces (buccal and lingual for anterior teeth). A six-point (0–5) semiquantitative ordinal scale, based on the changes in the tooth surface and the extent of surface covered with restoration, is used to score individual tooth surfaces [Table 2]. The sum of each tooth surface score (SS) or restoration score (RS) is divided by the number of evaluated surfaces (3 for posterior teeth and 2 for anterior teeth) to calculate the Mean Restorative Score and Mean SS.{Table 2}


PRDI is the first index designed specifically to assess RRC.


The index does not include incisal surfaces of anterior teeth as reasoned by the authors to avoid artificially inflating the tooth destruction scores due to wear (attrition and abrasion), thus limiting its validity and practical applicabilityThe qualitative elements of RRC, such as brownish/back discoloration, enamel cracks and fissures, enamel delamination, and crown alteration, were not taken into account.


Watson et al. in 2020, proposed this novel index for RRC assessment.[32] It allows for the rapid identification of the degree of RRC along with treatment strategies. This index takes into consideration 32 sets of teeth, and each tooth is divided into five surfaces. Thus, a healthy mouth consists of a total of 160 (32 × 5) tooth surfaces. The missing surface (MS) value is calculated by counting all the missing teeth surfaces (number of missing teeth X 5) irrespective of the etiology (extraction or congenitally missing). All the DMFSs (except the one with attrition and abrasion) comprise the total DMFS value. The DMF value is calculated by subtracting the MS value from the DMFS value. The visual changes in the tooth surface are used to determine the stage of severity, and the percentage of teeth involved in the most severe stage is used for grading. A treatment algorithm is proposed for managed of teeth based on the stage and grade of RRC [Table 3].{Table 3}


This allows for accurate capturing of the unique pattern of RRC in the anterior regionIt eliminates the need for hypothesizing reasons for missing teethProvide directions regarding the treatment of affected teeth.


The index does not provide information about caries progressionThe grading system does not include diffused punctate defects, which is one of the characteristic clinical patterns of RRC.


Dental indices can be used to measure the severity of dental disease and the effectiveness of therapy, allowing for cross-sectional comparisons. Dental caries, “a biofilm-mediated, diet modulated, multifactorial, noncommunicable, dynamic disease resulting in net mineral loss of dental hard tissues,” is a widely prevalent dental disease. RRC are characterized by caries lesions on otherwise resistant tooth surfaces driven by biomechanical changes in tooth structure and xerostomia associated with radiation therapy. RRC differs from conventional caries in clinical appearance, development, and progression. However, the majority of epidemiologic studies have used indices proposed for conventional caries to study the incidence and prevalence of RRCs.

DMFT/S index is the most widely used caries assessment tool for radiation caries.[33],[34] A systematic review reported the mean prevalence of radiation caries as 28.1%, where the mean DMFT of irradiated patients was 9.19.[5] A study by Konjhodzic-Prcic et al., in 2010, used the DMFT index and found that the incidence of radiation caries went from 19.4 to 23.9 following 6 months of radiation therapy, which is a significant increase.[35] de Pauli Paglioni et al. attempted to establish a link between radiation caries and QoL in their multicenter study. The patients were divided into two groups: The study group (patients with at least 1 year of RT completion who developed RRC) and the control group (patients with at least 1 year of RT completion who did not develop RRC). Physical and social-emotional functioning domains were used to calculate the QoL score. DMFT index was used for caries assessment. They discovered that the mean DMFT and QoL scores were 30.5 and 878.1 in the study group and 20.7 and 927.2 in the control group, respectively. They reported that RRC has a detrimental effect on the QoL of individuals with HNC.[23]

ICDAS index has been used widely in the assessment of conventional dental caries. However, limited literature is available for its use in the assessment of radiation caries. In 2008, Walker et al. developed the PRDI as a pioneering index designed specifically for RRC. The authors assessed the reliability of the clinical index and found that it demonstrated excellent intra- and inter-examiner reliability.[31] Palmier. et al. compared the validity of ICDAS and PRDI for the assessment of radiation caries.[36] They observed that both ICDAS and PRDI underestimate the clinical expressivity of post-radiation caries by not including the whole qualitative clinical spectrum of radiation caries, such as enamel cracks, delamination, crown amputation, atypical lesions topography (incisal/cuspal caries), and surface color alterations. They emphasized the dire need for a more comprehensive caries assessment tool that caters to the atypical pattern of radiation caries. Palmier et al., through a study on the reliability of PRDI and ICDAS, concluded that ICDAS is used for conventional caries rather than RRC, and PRDI is an ex vivo index that does not fully represent the true clinical picture of radiation caries.[37]

In an attempt to overcome the aforementioned issues, Watson et al. in 2020, developed a novel caries assessment index called DMFS160.[32] First, it focuses on the inclusion of incisal edge caries which allows for a more accurate representation of the damaged dentition. Second, the index acknowledges the qualitative component of radiation caries by addressing surface discoloration, enamel delamination, and crown amputation in its staging. Third, the index separates MSs and decayed/filled surfaces, which provides further context for the DMFS160 value. Furthermore, the staging and grading allow quick identification of the overalls state of the patient's dentition and making a required treatment decision. The DMFS 160 index looks promising and practical for use as it includes all the dental surfaces and proposes a treatment for the management of RRC. However, clinical studies are required to generate the data on its applicability and reliability in the clinical scenario.

Prevention and reduction of radiation-related side effects are essential for reducing the incidence of RRC and improving the oral health and QoL of patients. Intensity-modulated radiation therapy (IMRT) is a recently developed RT approach that provides for reduced induced damage and improved survival as compared to the conventional two-field radiation therapy. Duarte et al. compared the dental health of patients with head and neck cancer receiving IMRT versus conventional radiation therapy. They observed that patients treated with IMRT exhibited significantly lesser xerostomia, mucositis, and fewer required post treatment dental extraction as compared to those treated with conventional RT.[38] However, no studies were found in the literature using specific indices for measurement radiation caries after IMRT.

Restricted mouth opening is a challenge for dental evaluation of patients with head and neck cancers. This often leads to underreporting of the disease. With the advancements in technology, equipment like intraoral cameras can be used to overcome the constraint of limited visualization of dentition in these patients. Furthermore, the integration of artificial intelligence for caries detection and treatment planning can aid in objectively assessing and grading the RRC process, which presents a spectrum of clinical presentations.


PRDI and DMFS160 are the only two indices that have been specifically designed to assess RRC. Although DMFS160 being more comprehensive, appears to be promising and specific to radiation caries assessment compared to other indices used previously, more studies need to be done to assess its clinical viability.

Financial support and sponsorship

This study was supported by the Indian Council of Medical Research. (No. 5/4/2-8/OralHealth/2021-NCD-II).

Conflicts of interest

There are no conflicts of interest.


1Vigneswaran N, Williams MD. Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral Maxillofac Surg Clin North Am 2014;26:123-41.
2Sharma S, Satyanarayana L, Asthana S, Shivalingesh KK, Goutham BS, Ramachandra S. Oral cancer statistics in India on the basis of first report of 29 population-based cancer registries. J Oral Maxillofac Pathol 2018;22:18-26.
3Yeh SA. Radiotherapy for head and neck cancer. Semin Plast Surg 2010;24:127-36.
4Berkey FJ. Managing the adverse effects of radiation therapy. Am Fam Physician 2010;82:381-8, 394.
5Hong CH, Napeñas JJ, Hodgson BD, Stokman MA, Mathers-Stauffer V, Elting LS, et al. A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer 2010;18:1007-21.
6Dobroś K, Hajto-Bryk J, Wróblewska M, Zarzecka J. Radiation-induced caries as the late effect of radiation therapy in the head and neck region. Contemp Oncol (Pozn) 2016;20:287-90.
7de Barros da Cunha SR, Ramos PA, Nesrallah AC, Parahyba CJ, Fregnani ER, Aranha AC. The effects of ionizing radiation on the oral cavity. J Contemp Dent Pract 2015;16:679-87.
8Naidu MU, Ramana GV, Rani PU, Suman A, Roy P. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia 2004;6:423-31.
9Bulancea BP, Checherita LE, Foia GL, Stamatin O, Teslaru S, Lupu IC, et al. The quantification of salivary flow and pH and stomatognathic system rehabilitation interference in patients with oral diseases, post-radiotherapy. Appl Sci 2022;12:3708.
10Epstein JB, Chin EA, Jacobson JJ, Rishiraj B, Le N. The relationships among fluoride, cariogenic oral flora, and salivary flow rate during radiation therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:286-92.
11Keene HJ, Daly T, Brown LR, Dreizen S, Drane JB, Horton IM, et al. Dental caries and Streptococcus mutans prevalence in cancer patients with irradiation-induced xerostomia: 1-13 years after radiotherapy. Caries Res 1981;15:416-27.
12Xiao C, Hanlon A, Zhang Q, Ang K, Rosenthal DI, Nguyen-Tan PF, et al. Symptom clusters in patients with head and neck cancer receiving concurrent chemoradiotherapy. Oral Oncol 2013;49:360-6.
13Ribeiro AC, Lopes MA, Brandão TB, Santos-Silva AR. Clustering of oral symptoms versus radiation-induced apical periodontitis. Clin Oral Investing 2013;17:337.
14Lu H, Zhao Q, Guo J, Zeng B, Yu X, Yu D, et al. Direct radiation-induced effects on dental hard tissue. Radiat Oncol 2019;14:5.
15Madrid CC, de Pauli Paglioni M, Line SR, Vasconcelos KG, Brandão TB, Lopes MA, et al. Structural analysis of enamel in teeth from head-and-neck cancer patients who underwent radiotherapy. Caries Res 2017;51:119-28.
16Walker MP, Wichman B, Cheng AL, Coster J, Williams KB. Impact of radiotherapy dose on dentition breakdown in head and neck cancer patients. Pract Radiat Oncol 2011;1:142-8.
17Qing P, Huang S, Gao S, Qian L, Yu H. Effect of gamma irradiation on the wear behaviour of human tooth enamel. Sci Rep 2015;5:11568.
18Arsenault AL, Robinson BW. The dentino-enamel junction: A structural and microanalytical study of early mineralization. Calcif Tissue Int 1989;45:111-21.
19Collett WK, Thonard JC. The effect of fractional radiation on dentinogenesis in the rat. J Dent Res 1965;44:84-90.
20Kaste SC, Hopkins KP, Jenkins JJ 3rd. Abnormal odontogenesis in children treated with radiation and chemotherapy: Imaging findings. AJR Am J Roentgenol 1994;162:1407-11.
21Dahllöf G, Rozell B, Forsberg CM, Borgström B. Histologic changes in dental morphology induced by high dose chemotherapy and total body irradiation. Oral Surg Oral Med Oral Pathol 1994;77:56-60.
22De Moor RJ, Stassen IG, van 't Veldt Y, Torbeyns D, Hommez GM. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic head- and neck-irradiated cancer patients. Clin Oral Investig 2011;15:31-8.
23de Pauli Paglioni M, Palmier NR, Prado-Ribeiro AC, Fregnani ER, Gavião MB, Brandão TB, et al. The impact of radiation caries in the quality of life of head and neck cancer patients. Support Care Cancer 2020;28:2977-84.
24Knutson JW. Epidemiological trend patterns of dental caries prevalence data. J Am Dent Assoc 1958;57:821-9.
25Pitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) – Methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013;41:e41-52.
26Dikmen B. Icdas II criteria (international caries detection and assessment system). J Istanb Univ Fac Dent 2015;49:63-72.
27International Caries Detection and Assessment System Coordinating Committee. Criteria Manual: International Caries Detection and Assessment System (ICDAS II). In Report of a Workshop Baltimore, MD; 2005. Available from: [Last accessed on 2022 Apr 22].
28Gugnani N, Pandit IK, Srivastava N, Gupta M, Sharma M. International Caries Detection and Assessment System (ICDAS): A new concept. Int J Clin Pediatr Dent 2011;4:93-100.
29Braga MM, Oliveira LB, Bonini GA, Bönecker M, Mendes FM. Feasibility of the International Caries Detection and Assessment System (ICDAS-II) in epidemiological surveys and comparability with standard World Health Organization criteria. Caries Res 2009;43:245-9.
30World Health Organization. Oral Health Surveys: Basic Methods. 4th ed. Geneva: World Health Organization; 1997. Available from: [Last accessed on 2022 Apr 22].
31Walker MP, Williams KB, Wichman B. Post-radiation dental index: Development and reliability. Support Care Cancer 2008;16:525-30.
32Watson E, Eason B, Kreher M, Glogauer M. The DMFS160: A new index for measuring post-radiation caries. Oral Oncol 2020;108:104823.
33Becker T, Levin L, Shochat T, Einy S. How much does the DMFT index underestimate the need for restorative care? J Dent Educ 2007;71:677-81.
34Benigeri M, Payette M, Brodeur JM. Comparison between the DMF indices and two alternative composite indicators of dental health. Community Dent Oral Epidemiol 1998;26:303-9.
35Konjhodzic-Prcic A, Keros J, Ajanovic M, Smajkic N, Hasic-Brankovic L. Incidence of radiation caries in patients undergoing radiation therapy in the head and neck region. Pesqui Bras Odontopediatria Clin Integr 2010;10:489-92.
36Palmier NR, Ribeiro AC, Fonsêca JM, Salvajoli JV, Vargas PA, Lopes MA, et al. Radiation-related caries assessment through the International Caries Detection and Assessment System and the Post-Radiation Dental Index. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;124:542-7.
37Palmier NR, Ribeiro AC, Lopes MA, Brandão TB, Santos-Silva AR. Reliability of ICDAS and post-radiation dental index in radiation caries. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;124:137.
38Duarte VM, Liu YF, Rafizadeh S, Tajima T, Nabili V, Wang MB. Comparison of dental health of patients with head and neck cancer receiving IMRT vs. conventional radiation. Otolaryngol Head Neck Surg 2014;150:81-6.