What is your approach to counseling patients who require definitive radiation therapy to the head and neck but for whatever reason, cannot/will not undergo recommended extractions?

I am fortunate to work at a center where we have dentists and oral surgeons on-site. They carefully evaluate all our patients scheduled to undergo H&N RT, make recommendations, and perform the extractions. In the unusual scenario where the patient refuses recommended extractions, I proceed with treatment as planned while ensuring to minimize the dose to the mandible. I explain to the patients that they are at risk of dental caries (far more common) and mandibular osteoradionecrosis (less common with modern IMRT planning).

There are many published guidelines for recommended safe doses to the mandible (e.g., Verduijn et al., PMID 37659662).

In terms of risk of ORN, the highest risk is for the posterior mandible, followed by the anterior mandible, posterior maxilla, and then anterior maxilla. Occasionally, we have patients who need to be started on an urgent basis, and we don't have the luxury of time to get all planned dental evaluations, etc. In these cases, treating the cancer always takes precedence.

I don't always insist on dental appointments for patients being treated with limited field RT, as for T1 glottic ca.

Proceed with RT.