ArticlePDF AvailableLiterature Review

A review of the Marx protocols: prevention and management of osteoradionecrosis by combining surgery and hyperbaric oxygen therapy

Authors:

Abstract

The 30/10 protocol is employed in the treatment of established osteoradionecrosis. No surgery should be attempted before the first 30 HBO treatments have provided sufficient angiogenesis to support surgical wounding. After 30 treatments surgical management can be staged according to the extent of improvement achieved after HBO and the size of sequestrum or area of osteolysis. If the ORN extends to the inferior border of the mandible or if it manifests as an orocutaneous fistula or pathological fracture, discontinuity resection of the necrotic bone and soft tissue will be required to resolve the disease. Unless HBO and surgery are combined in the management of ORN, the results are not long lasting or satisfactory. Even though resection of stage three ORN seems unduly aggressive, it has stood the test of time. By using the Marx protocols in the treatment of ORN, more than 95 per cent of patients can be successfully cured of their disease with predictable, functional and aesthetically acceptable outcomes.
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... cellular death and collagenolysis that exceed cellular replication and collagen synthesis) followed by a nonhealing wound (e.g. tooth extraction), in which oxygen and metabolic demand exceed supply thus inhibiting substitution of cells to complete the turnover for the maintenance of homeostasis and wound cicatrisation [1][2][3]. The affected cells are the ones of vascular endothelium, fibroblasts which makes stroma and parenchyma cells [3]. ...
... Various predisposing factors associated are trauma (from surgical procedures), active periodontal disease or denture trauma, idiopathic or spontaneous necrosis, high-dose radiation >65Gray, field of radiation (volume of the mandible included in the field and proximity of maximal dosing to bone), use of implant sources too close to the bone, and combined interstitial and external beam irradiation. Marx staging and treatment of osteoradionecrosis was considered the most effective tool to approach such patients [2,3]. The three stages classification proposed by Marx and Myers appears to be the most relevant: ...
... The condition is characterized by a triad of hypoxia, hypocellularity and hypovascularity (Mader et al., 1990). The most commonly followed testament is based on 'The Marx University of Miami Protocol', which includes a combination of antibiotics, surgical debridement and HBOT (Balaji and Balaji, 2019;Cronje, 1998). The treatment protocol involves 30 HBOT sessions depending on the responsiveness of the necrosed bone. ...
Article
Full-text available
The outbreak of the SARS CoV2 ' pandemic' is believed to have originated in Wuhan in 2019 as a spread from bats to humans. It is a highly communicable infection-causing rapid human to human transmission of the virus by virtue of its infectious and nature. The virus has affected millions of people worldwide, with numbers still rising with each passing day. Depleting oxygen saturation levels is amongst the prime concerns in the majority of infected patients. Nasal prongs, face masks, mechanical ventilation and membrane (ECMO) are the commonly used modes of oxygen delivery in such patients. These methods though mostly successful, at times fail to restore the depleting oxygen levels to normal. oxygen therapy (HBOT) involves the administration of 100% O2 in a special chamber whose pressure is maintained at a level greater than 1 ATP. The main purpose for raising the pressure within the chamber is that as the atmospheric pressure increases, the saturation levels of oxygen in the blood also increase, which eventually result in increased overall tissue oxygenation. This article provides a systematic and wholesome review on the basic principle of oxygen therapy, its effects on the body at a microscopic and macroscopic level, its various uses and its suitability as an for the treatment of select COVID-19 infected patients.
... Owing to lack of the facility for HBO therapy, none of the reviewed patients were subjected to it. 16 Fatality was seen in two immunocompromised patients with mucormycosis (15.38%). Mucormycosis is an aggressive fungal infection with risk for widespread dissemination. ...
Article
Background Osteomyelitis of the jawbone is mostly secondary to radiation exposure or bone remodelling drugs, with the mandible being commonly involved. Maxillary osteomyelitis risk is low owing to its high vascularity. This study was undertaken to evaluate risk factors, presentation, management and outcomes of maxillary osteomyelitis caused due to reasons other than irradiation and bone remodelling drugs. Methods Patient records diagnosed with maxillary osteomyelitis were evaluated for demographic details, risk factors, clinical presentation, radiological features, treatment performed and outcomes. Results In 38 patients with non-irradiated and non-drug–induced osteomyelitis, 13 involved the maxilla, seven were localized to the posterior maxilla and 10 showed paranasal sinus involvement. Dissemination to the cavernous sinus and cerebral spread was seen in one. Clinical findings included oroantral communication, pain and draining sinus. Imaging showed diffuse bone destruction areas with or without evidence of bony sequestrum. The most common systemic risk factor was diabetes mellitus. Maxillary osteomyelitis was associated with tooth extraction in eight cases. Surgical management included debridement, sequestrectomy, functional endoscopic sinus surgery, maxillectomy and reconstruction of soft tissue defect with local and regional flaps. Complete recovery was seen in 11 patients. Mortality was seen in two patients with mucormycosis having disseminated infection. Conclusion Compared with previous literature, a relatively higher ratio of maxillary involvement was reported. Diabetes mellitus was the most common risk factor, followed by osteopetrosis and tooth extraction. Osteomyelitis secondary to mucormycosis in immunocompetent patients was relatively localized and gave favourable response to management compared with patients with diabetes mellitus.
... 5 There are many adjunct treatment options for ORN prior to, during, or after surgery. 6 For example, hyperbaric oxygen therapy (HBOT) may enhance treatment outcomes for ORN. Further studies, however, are still required to conclusively demonstrate its effectiveness. ...
Article
Full-text available
This study enrolled patients with stage 3 osteoradionecrosis. There were three treatment modalities: antibiotics, hyperbaric oxygen therapy (HBOT), and surgery. Complete healing was the primary outcome. Multiple logistic regression analysis demonstrated that surgery with HBOT improved wound healing better than HBOT alone.
... For treatment of establish ORN the patient would need 30 sessions before the surgical treatment for ORN such as sequestrectomy and another 10 sessions after that surgery (30/10 protocol). [18] However, due to variations in patients' compliance and tolerance to the treatment, it is possible to have variation in the total sessions received. Apart from the protocol for ORN, there is no establish guide on the total treatment duration prescribed, both in terms of cumulative time or number of sessions. ...
Article
Full-text available
Introduction: Hyperbaric oxygen therapy (HBOT) has been suggested to be beneficial in managing compromised acute and chronic wounds. To shed some light on its effectiveness in head‑and‑neck wounds, a retrospective review on the use of HBOT was done. Materials and Methods: The medical records of patients receiving HBOT for head-and-neck conditions were reviewed. The demographics and clinical data were collected. Results: Seventeen patients were identified. Four major indications for therapy were identified being osteoradionecrosis (ORN) treatment, ORN prophylaxis, treatment of compromised flaps/grafts, and treatment of medication‑related osteonecrosis of the jaw. Favorable outcome following HBOT was seen in 77% of patients. In the treatment of ORN, 56% cases treated were successful. In the remaining groups, 100% success rates were obtained. The majority of patients had HBOT as an adjunctive treatment. HBOT as an adjunct was successful in 71% of patients, while prophylactic HBOT were successful in all patients. Complications including ear barotrauma and sinus squeeze were seen in 24% of patients. Conclusions: HBOT can be successfully used in various head‑and‑neck conditions, especially when used in cases with compromised flaps/graft or ORN prophylaxis. It is well tolerated and thus provides a valid adjunctive therapy in the management of tissue with compromised healing capability in the head-and-neck region.
... For treatment of establish ORN the patient would need 30 sessions before the surgical treatment for ORN such as sequestrectomy and another 10 sessions after that surgery (30/10 protocol). [18] However, due to variations in patients' compliance and tolerance to the treatment, it is possible to have variation in the total sessions received. Apart from the protocol for ORN, there is no establish guide on the total treatment duration prescribed, both in terms of cumulative time or number of sessions. ...
Article
Full-text available
Bone augmentation is an extremely common procedure in implant dentistry today because of significant advancements with reactive biomaterials, a better understanding of the mechanism of action that is found with growth factors contained in platelets, and improvements in surgical techniques. The expectation is for the surgeon to place the dental implant in the position that best serves the requirements of the prosthetic restorations. With the increasing demands that patients have for ideal prosthetic results, surgeons are expected to predictably augment both hard and soft tissues to provide the anticipated esthetic and functional outcomes. Bone grafting can be performed before, during, and after the implant placement; however, these augmentation procedures come with increased cost, the risk of complications such as infection or failure, and lengthening of the total treatment time. In addition, a plethora of grafting materials are available commercially, where they are often inadequately studied, or there is minimal information regarding their predictability or long‐term success, or ability to support dental implants. It is clear that although the surgical field has seen major progress since early implant surgical techniques in the 1980s, major challenges still exist with hard tissue augmentation procedures. This review will discuss these challenges that are increased and often specific to bone graft healing, and which are becoming more common as implant site development often requires bone augmentation to improve volume or contour deficiencies. The risk factors that patients may present with that will affect outcomes with bone augmentation procedures are identified, and recommendations for the prevention of complications or managing complications once they have occurred are provided.
Chapter
Radiotherapy has been used for over a 100 years to treat certain cancers, either as a curative, adjuvant or palliative treatment. Although radiation therapy is used to kill cancerous cells, it also results in damage to healthy cells, which leads to a variety of acute and long-term complications. Side effects may be due to radiation-induced DNA mutations, cell death within irradiated organs, ischaemia due to the effects of radiation on small blood vessels or due to perturbed inflammatory and repair responses.The skin is particularly affected with atrophy, soft-tissue fibrosis and microvascular damage.
Article
Background: Mandibular osteoradionecrosis (ORN) is among the most severe and devastating complications that can occur following combined management of head and neck cancer. This study constitutes a review of 13 patients who underwent intra-oral cancer resection followed by radiotherapy, and thereafter developed ORN of the mandible. The anatomical localization of primary disease focus, malignancy type, and the time between radiotherapy termination and the clinical diagnosis of ORN were all investigated. The association between ORN, oral tissue injury and dental condition were also checked. The treatment modality used and the outcome were analysed. Material and methods: The clinical records and treatment plans of 13 ORN patients (10 men, 3 women) treated from January 1993 through December 2003 in the Department of Maxillofacial Surgery in Katowice were analysed retrospectively. Results: Of the 13 patients, 11 were referred for irradiation therapy for oral squamous cell carcinoma, 1 for sarcoma of the mandible, and 1 for histiocytosis. The average duration of radiation therapy, and the clinical diagnosis of ORN was 20 months (range: 1 month to 7 years), In most cases ORN resulted from an injury. Initially all patients were given conservative treatment, which turned out to be effective in 7 cases. In the remaining 6 patients, further ORN progress was observed. Thus, a segmental mandibulectomy or hemi-mandibulectomy with a simultaneous reconstruction with regional flaps was performed. Conclusions: Mandibular osteoradionecrosis occurs mostly after associated treatment for oral squamous cell carcinoma. Each surgical intervention (such as dental extraction) in the irradiated region is the main risk factor for the development of ORN. In cases with acute and rapid progressive ORN, conservative treatment does not seem to be effective.
Article
Introducción: La oxigenoterapia hiperbárica (OHB) es una modalidad terapéutica que se fundamenta en la obtención de presiones parciales de oxígeno elevadas en sangre, al respirar oxígeno puro, en el interior de una cámara hiperbárica a una presión superior a la atmosférica. Sus acciones incluyen efectos hemodinámicos, acciones sobre la inmunidad y el transporte de O2. Este amplio espectro de efectos facilita que sus recomendaciones puedan incluir una gran variedad de indicaciones, algunas de ellas controvertidas. Objetivos: Conocer las patologías de los pacientes tratados con OHB en la Comunidad Autónoma de Madrid (CAM) y revisar la evidencia científica al respecto. Método: En la actualidad la cámara hiperbárica del Servicio de MSB (Medicina Subacuática) del HCD (Hospital Central de la Defensa) es la de referencia en la CAM. Se revisaron las historias clínicas de los pacientes atendidos entre Febrero 2013 y Junio 2014. Se recogieron las siguientes variables: 1) Enfermos aceptados y desestimados para el tratamiento. 2) Edad y sexo de los pacientes tratados. 3) Patología por la que se indicaba el tratamiento. 4) Complicaciones observadas en relación con la OHB. Resultados: Se aceptaron para tratamiento 113 enfermos procedentes de 15 Hospitales de la CAM. Se desestimaron para tratamiento con OHB a 22 pacientes por patologías o tratamientos activos que no hacían aconsejable el tratamiento con OHB en ese momento. El 59,82 % eran hombres y el 40,18 % mujeres. Edad media 64,72 años. Las indicaciones principales de tratamiento fueron las lesiones radio inducidas 52,21 % de los casos (n=59) y las úlceras y heridas de evolución tórpida con mala respuesta a tratamiento convencional 23 % de los casos (n=26). El tratamiento tuvo que ser suspendido en 8 pacientes (7,14 % de los tratados) por mala tolerancia o complicaciones leves. Discusión y conclusiones: Las indicaciones de OHB en nuestra muestra comprenden un amplio número de patologías. Las lesiones radio inducidas son la indicación más frecuente de los enfermos tratados con OHB en el HCD. En este grupo destaca la osteorradionecrosis de mandíbula (ORNM) tras radioterapia (RT) en tumores de cabeza y cuello. Todas las indicaciones de OHB de la muestra presentada cuentan con estudios que avalan su uso, aunque no existen para ninguna de ellas estudios randomizados controlados, doble ciego. Las complicaciones que observamos en el tratamiento con OHB en nuestra muestra son leves por lo que la podemos considerar un tratamiento seguro. Creemos que la OHB ofrece una gran oportunidad para investigar la evidencia científica firme que avale sus indicaciones en discusión.
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