Incidence and prevention of osteoradionecrosis after dental extraction in irradiated patients: A systematic review
This systematic review aims to identify and review the best available evidence to answer the clinical question 'What are the incidence and the factors influencing the development of osteoradionecrosis after tooth extraction in irradiated patients?'. A systematic review of published articles on post-irradiation extraction was performed via electronic search of the Medline, Ovid, Embase and Cochrane Library databases. Additional studies were identified by manual reference list search. Evaluation and critical appraisal were done in 3 stages by two independent reviewers and any disagreement was resolved by discussion with a third party. 19 articles were selected for the final analysis. The total incidence of osteoradionecrosis after tooth extraction in irradiated patients was 7%. When extractions were performed in conjunction with prophylactic hyperbaric oxygen, the incidence was 4% while extraction in conjunction with antibiotics gave an incidence of 6%. This systematic review found that while the incidence of osteoradionecrosis after post-irradiation tooth extractions is low, the extraction of mandibular teeth within the radiation field in patients who received a radiation dose higher than 60Gy represents the highest risk of developing osteoradionecrosis. Based on weak evidence, prophylactic hyperbaric oxygen is effective in reducing the risk of developing osteoradionecrosis after post-radiation extractions.
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- "As one of the worst complications of radiotherapy, osteoradionecrosis of jaws (ORNJ) is a serious delayed injury, characterized by bone tissue necrosis and failure to heal for 3– 6 months . Surgery is the main treatment for ORNJ at present . "
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ABSTRACT: Osteoradionecrosis of jaws (ORNJ) is a serious complication of radiotherapy for patients with head and neck cancer. As of yet, no universally accepted treatment exists for this chronic pathologic condition. It has been shown that ultrasound is an effective, noninvasive adjunctive therapy in ORNJ, as ultrasound can result in the increase of angiogenesis and bone production, which are essential for ORNJ healing. Recently, low-frequency ultrasound has been demonstrated to enhance the transdermal delivery of macromolecules and hydrophilic drugs (low-frequency sonophoresis, LFS). As a biological macromolecule, basic fibroblast growth factor (bFGF) also has potential osteoinductive and angiogenic properties. Herein, we present a hypothesis that LFS-mediated transdermal bFGF delivery is capable of improving the healing of ORNJ and will be a new effective adjunctive therapy to surgery. This treatment combines low-frequency ultrasound with bFGF to respectively promote vascularly compromised bone and soft tissue wound healing, and is expected to be more effective than ultrasound therapy alone.
Available from: Artur Gevorgyan
- "ORN is rare with conventional radiation doses of less than 60Gy, while the rate in those irradiated with >60 Gy is around 12%  IMRT can reduce the dose delivered to the salivary glands and reduce the rate of xerostomia, as well as other radiation related toxicities. A study from the University of Michigan reported no cases of ORN of the mandible at a median follow-up of 34 months after IMRT for head and neck cancer, using a strict prophylactic dental care policy . "
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ABSTRACT: Osteoradionecrosis (ORN) defines exposed irradiated bone, which fails to heal over a period of 3--6 months without evidence of residual or recurrent tumor. In the previous decades, a staging and treatment protocol suggested by Marx, has been dominated the approach to ORN. However, recently this paradigm is shifting. The purpose of this study was to evaluate our institutional experience in managing ORN through a retrospective review of case series from a large urban academic cancer centre.
A retrospective chart review was conducted to include all ORN cases from 2003 to 2009 diagnosed at the Department of Otolaryngology -- Head and Neck Surgery and the Department of Dentistry. The staging of ORN was assessed as affected by tumor site, tumor stage, radiotherapy modality and dose, chemotherapy, dental work, and time to diagnosis. The effectiveness of hyperbaric oxygen therapy (HBO) and surgery in the management of ORN was evaluated.
Fourteen cases of ORN were documented (incidence 0.84%). Primary subsites included tonsils, tongue, retromolar trigone, parotid gland, soft palate and buccal mucosa. There were 5 (35.7%) stage 1, 3 (21.4%) stage 2, and 6 (42.9%) stage 3 cases. ORN severity was not significantly associated with gender, smoking, alcohol use, tumor site, T stage, N stage, AJCC stage, or treatment modality (radiation alone, surgery with adjuvant radiation or adjuvant chemoradiation). Patients treated with intensity-modulated radiotherapy developed less severe ORN compared to those treated with conventional radiotherapy (p < 0.015). ORN stage did not correlate with radiation dose. In one patient only dental procedures were performed following radiation and could be implicated as the cause of ORN. HBO therapy failed to prevent ORN progression. Surgical treatment was required for most stage 2 (partial resections and free tissue transfers) and stage 3 patients (mandibulectomies and free tissue transfers, including two flaps in one patient). At an average follow up of 26 months, all patients were cancer-free, and there was no evidence of ORN in 84% of patients.
In early ORN, we advocate a conservative approach with local care, while reserving radical resections with robust reconstruction with vascularized free tissue for advanced stages.
Available from: An-Lin Cheng
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ABSTRACT: PURPOSE: To evaluate the severity of post-radiation dental lesions and possible correlation with radiation dose to the teeth in patients treated for head and neck cancers. METHODS AND MATERIALS: Data from 93 head and neck radiotherapy patients treated between 1997 and 2008 were analyzed retrospectively. The main effect, radiation dose to the individual teeth, was evaluated with covariates of elapsed time after radiation, xerostomia, topical fluoride use, and oral hygiene status included. Patients' radiotherapy plans were used to calculate cumulative exposure for each tooth. Patients' teeth were evaluated using a validated index and then categorized as having none/slight or moderate/severe post-radiation damage. RESULTS: Patients (31 females, 62 males) ranged in age from 18-82 yrs (mean=57). The number of teeth/patient ranged from 3-30 (mean=20) with a total of 1873 teeth evaluated. Overall, 51% of teeth had moderate/severe damage, with the remaining having little or none. Using odds ratios and 95% confidence intervals, the odds for moderate/severe damage were 2-3x greater for teeth exposed to between 30-60 Gy as compared to no radiation. However, for teeth exposed to ≥60 Gy as compared to no radiation the odds of moderate/severe tooth damage was greater by a magnitude of 10 times. CONCLUSIONS: The results indicate that there is minimal tooth damage below 30 Gy (salivary gland threshold), a greater than 1:1 increased dose-response between 30-60y likely related to salivary gland damage, and a critical threshold of ≥60Gy which may be linked to direct effects of radiation on tooth structure. These findings suggest that care should be taken during the treatment planning process to limit tooth dose, and when clinically possible to limit tooth dose to less than 60 Gy.
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