Dosimetric consideration for patients with dental filling materials undergoing irradiation of oral cavity using RapidArc: challenges and solution

In this study, we investigate the effect of dental filling materials (DFM) on RapidArcTM treatment plans and delivery in a patient undergoing radiotherapy treatment. The presence of DFM creates uncertainties in CT number and causes long streaking artifacts in the reconstructed images which greatly affect the dose distribution inside the oral cavity. The influence of extensive dental filling artifacts on dose distribution was performed using a geometrically well defined head and neck IMRT verification phantom (PTW, Freiburg, Germany) together with inserts from DFM (Amalgam, 11.3 g/cm3). The phantom was scanned using Siemens SOMATOM Sensation CT simulator (Siemens AG, Germany) under standard head and neck imaging protocol (120 kV, 120 mAs, voxel size 1×1×2 mm3). Three RapidArcTM plans were created in the Varian Eclipse treatment planning System (TPS) to treat oral cavity using the same CT dataset including; 1) raw CT image, 2) streaking artifacts replaced with a mask of 10 HU and 3) 2 cm thick 6000 HU virtual filter (a volume around the teeth in TPS to mimic extra attenuation). The virtual filter thickness optimization was purely based on measured PDD data acquired with DFM and the calculation in Eclipse Planning System using direct beam. The dose delivery and distribution for the three plans was verified using Gafchromic EBT2 (International Specialty Product, Wayne, NJ, USA) film measurements. The artifact mask and virtual filter around the teeth in the planning was found very useful to reduce the discrepancies between the dose plan and delivery. From clinical point of view, these results can be helpful to understand the increase of mucositis in patient having DFM, and further investigation is underway for clinical solution.