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Osteoradionecrosis
http://www.ddrc.org
Osteoradionecrosis
and
hyperbaric
oxygen:
Osteoradionecrosis (ORN) is a complication of
radiation exposure, occurring when irradicated bone
becomes devitalised. The presentation of ORN ranges
from necrotic soft tissue damage, to bone erosion, to
pathological fractures. Contributing factors to the
development of ORN are well known. Radiation
dosage, delivery and fractionation and elapsed time
since radiation and its contribution to ORN have been
studied by Marx (1984), Beumer et al. (1984),
Maxymiw et al. (1991) and Curi et al. (1997). Oral
hygiene, alcohol and tobacco use, and concomitant
chemotherapy also play a role.
Hyperbaric oxygen (HBO) increases the blood-tissue
oxygen gradient which enhances the diffusion of
oxygen into hypoxic tissues. The increased oxygen
supply
stimulates
fibroblast
proliferation,
angiogenesis, and collagen formation. Additionally the
increased oxygen is bactericidal and bacteriostatic.
prophylactic hyperbaric oxygen is effective in reducing
the risk of developing ORN after post-radiation
extractions. In a review and rationale for treatment
planning Schoen et al (2003) suggested if surgery after
radiotherapy is indicated, measures to prevent
implant loss and development of ORN have to be
considered e.g antibiotic prophylaxis and/or pretreatment with HBO. HBO therapy used as an
adjunctive treatment for ORN has been associated
with improved success rates in the early and
intermediate stages. Freiberger et al (2009) in a
retrospective study of 65 patients concluded that
multi-modality therapy is effective for ORN when less
intensive therapies have failed, and McKenzie et al
(1993) in a retrospective review found the
combination
of
HBO,
other
conservative
management, and surgery will optimize treatment
results in many patients.
@ddrcplymouth
When is HBO appropriate: HBO may be used to aid
wound healing in the presence of ORN or can be
administered peri-operatively to help demarcate the
non-viable bone or tissue prior to debridement and
then used post-operatively to aid wound healing.
Evidence: A randomised controlled trial carried out by
Bennett et al (2011) found evidence that HBO therapy
is more likely to achieve mucosal coverage in the
presence of ORN and that it also appears to reduce
the chance of ORN following tooth extraction in an
irradiated field. HBO should be considered a
prophylactic, and/or pre-treatment measure to
prevent dental implant loss and development of
radionecrosis. Nabil et al (2011) carried out a
systematic review of published articles and found,
Referral pathway: A referral letter should be sent to
our Medical Director, Dr Christine Penny, explaining
the reason for referral and highlighting any significant
past medical history. Consultant referral is required
for treatment funded by the NHS although private
medical insurance is also an option. We will be happy
to discuss potential referrals if there is any uncertainty
about the appropriateness of HBO.
Arrangements will be made with the patient for an
appointment to assess suitability for treatment.
DDRC Healthcare | Hyperbaric Medical Centre | Plymouth | Devon | UK | PL6 8BU
References
Bennet M et al (2011)
Marx RE (1984)
HBOT for late radiation tissue injury.
Orn of jaws: review and update.
Cochrane library.
Hyperbaric Oxygen Rev 1984;12(5):78-128
Beumer J, Harrison R, Sanders B, Kurrasch M (1984)
Orn: predisposing factors and outcomes of therapy.
Head and Neck surgery 1984;6(4):819-27.
Maxymiw WG, Wood RE, Liu FF (1991).
Postradiation dental extractions without HBOT.
Oral Surg Oral Med Oral Pathol 1991;72(3):270-4
Bishop A (2008)
Role of oxygen in wound healing. J Wound Care. Vol
17,9:399-402
Curi MM,Dib LL (1997)
Orn of the jaws; a retrospective study of the
background factors and treatment in 104 cases.
J Oral Maxillofac Surg 1997;55(6):540-4
McKenzie MR, Wong FL, Epstein JB, Lepawsky
M.(1993)
HBO and postradiation osteonecrosis of the mandible.
European Journ Cancer B Oral Oncol 1993;29B(3):2017.
Nabil S, Samman N (2011)
Incidence and prevention of orn after dental
extraction in irradiated patients: a systematic review.
Int Jou Oral Maxillofac Surg 2011, 40:229-243.
Freiberger JJ (2009)
Utilty of HBO in treatment of bisphosphonate- related
orn of the jaws.
Journ of Oral and Maxillofac Surg
Jacobson As, Buchbinder D, Hu K, Urken ML (2010)
Paradigmn shifts in the management of orn of the
mandible.
Schoen PJ, Reintsema H, Raghoebar GM, Vissink A,
Roodenburg JLN (2003)
The use of implant retained mandibular prostheses in
the oral rehab of head and neck cancer patients. A
review and rationale for treatment planning.
Oral Oncology 40;9;862-871.
Oral Oncol 2010, 46:795-801
Store G and Boysen M (2000) .
Marx RE et al (1987)
Mandibular orn: clinical behaviour and diagnostic
aspects.
Studies in the radiobiology of orn and their clinical
significance.
Clinical Otolaryngology and Allied Sciences 2000.
Wiley online library.
Oral Surg Oral Med Oral Pathol 1987;64:379-90
DDRC Healthcare | Hyperbaric Medical Centre | Plymouth | Devon | UK | PL6 8BU