Tooth Extraction Timing After Head and Neck Radiotherapy: A Critical Reappraisal of Osteoradionecrosis Risk and Biological Vulnerability

Aims: To critically reappraise the post-radiotherapy tooth-extraction waiting-period paradigm and examine whether extraction timing is better interpreted within a broader framework of biological vulnerability than as an isolated temporal determinant of osteoradionecrosis of the jaws (ORNJ) risk. Methods: This narrative review purposively synthesized clinical guidelines, systematic reviews, clinical and dosimetric studies, foundational radiobiological literature, and epidemiological methodology relevant to post-radiotherapy extraction timing and ORNJ. Results: Available evidence does not establish a universally safe post-radiotherapy extraction interval or demonstrate that progressively longer delays confer greater protection against ORNJ. Contemporary radiobiology supports persistent vascular, cellular, fibroatrophic, and bone-remodeling abnormalities after radiotherapy. Observational timing studies may also be susceptible to selection-related and time-dependent biases, although these mechanisms have not been demonstrated uniformly across the literature. Mandibular radiation exposure is consistently associated with ORNJ risk, whereas different dosimetric parameters are not interchangeable. Evidence for a dose–timing interaction currently derives from a single retrospective cohort and remains hypothesis-generating. Conclusions: Extraction timing should not be interpreted in isolation. Current evidence supports considering elapsed time together with mandibular radiation exposure, local tissue condition, extraction indication, surgical factors, and host-related determinants, without presuming that any fixed waiting interval is inherently protective.