From the Guidelines
Osteoradionecrosis (ORN) is a mechanistically complex and clinically impactful condition characterized by nonhealing exposed oral bone in patients treated with radiation therapy for head and neck cancer, resulting in considerable morbidity. This condition is a serious complication of radiation therapy, most commonly affecting the jaw, and is defined by bone death due to radiation damage 1. The 2-year incidence of exposed bone has been reported to be 6.1%, with an incidence of confirmed ORN of 3.1% 1. Key factors contributing to ORN include poor oral health, radiation dose, and the presence of compromised teeth in the radiation field 1.
Prevention and Management
Prevention of ORN is crucial and involves pre-radiation dental evaluation, extraction of compromised teeth at least 14 days before radiation, and maintaining excellent oral hygiene 1. Prevention strategies, including interprofessional practice and patient education, can significantly enhance outcomes and reduce the risk of ORN. Management of ORN depends on the severity of the condition but may include conservative management with oral hygiene protocols, antibiotics, and pentoxifylline with vitamin E to improve blood flow and reduce inflammation 1. Advanced cases may require hyperbaric oxygen therapy and surgical intervention, including debridement or jaw reconstruction 1.
Importance of Early Detection and Long-Term Monitoring
Early detection and long-term monitoring of patients at risk for ORN are essential, as this condition can develop months or years after radiation treatment 1. Poor oral health, including ORN, can influence long-term survival of patients with head and neck cancer, highlighting the need for evidence-based interprofessional practice and ongoing patient education 1. By prioritizing prevention and early management, healthcare providers can reduce the morbidity and mortality associated with ORN and improve the quality of life for patients with head and neck cancer 1.
From the Research
Definition and Causes of Osteoradionecrosis
- Osteoradionecrosis (ORN) is a complication of radiotherapy, characterized by nonhealing, dead bone, and is not a state of infection 2.
- It is the result of functional and structural bony changes that may not be expressed for months or years 2.
- ORN can occur spontaneously or in response to wounding, and predisposing factors include absorbed radiation dose, fractionation, delivery modality, and dental status 2.
Pathogenesis and Treatment
- The pathogenesis of ORN has been reinvestigated, and it is now thought to be potentially amenable to treatment with pentoxifylline and tocopherol (vitamin E) 3, 4, 5.
- Treatment with pentoxifylline and tocopherol has shown promise in resolving ORN, with resolution rates ranging from 56% to 85% in some studies 3, 5.
- Hyperbaric oxygen (HBO) therapy has also been beneficial in the prevention and treatment of ORN, but its use is limited by availability, cost, and clinical contraindications 2, 6.
Prevention and Management
- Early intraoral evaluation, treatment, and adequate healing time prior to beginning radiotherapy can help reduce the incidence of ORN 2.
- A dental visit before commencing radiotherapy is highly advised to minimize the need for future dental extractions after irradiation, and thus the risk of ORN 6.
- Post-radiotherapy preventive strategies, such as antibiotics, HBO, and the combined use of pentoxifylline and tocopherol, have been proposed, but currently, there is a lack of established standards of care 6.