Osteoradionecrosis of the Jaw N

Review Article

Osteoradionecrosis of the jaw N. C. Indhu Rekka1, R. Sarah Sathiyawathie2*, Deepa Gurunathan3

ABSTRACT

Osteoradionecrosis (ORN) is a problem with bone healing, particularly in the jawbone. It can occur after high doses of radiation have decreased blood supply to the affected bone, causing the bone to die from lack of oxygen. Bones that have died are unable to heal properly after procedures or surgery involving them. The treatment of head and neck cancer remains a challenge. Despite advances in surgical reconstructive techniques, most patients will require adjuvant therapy in the form of radiotherapy or chemoradiotherapy to improve locoregional control. The short- and long-term side effects of radiotherapy can be difficult to treat. In this review, the causative effects and pathogenesis of ORN of the mandible will be highlighted. In addition, preventive measures and clinical features of radiotherapy-induced damage will be presented. Finally, medical and surgical management of ORN, as well as, reconstructive surgery of the mandible will be discussed. At the end of this paper, the reader should have up to date knowledge concerning the etiology, prevention, diagnosis, and treatment of patients with ORN of the mandible.

KEY WORDS: Hyperbaric oxygen therapy, Osteoradionecrosis, Radiation

INTRODUCTION the bone. Osteonecrosis can also occur without trauma or disease. This is called idiopathic which means it Osteoradionecrosis (ORN) is a possible complication occurs without any known cause. Some of the most following radiotherapy. Irradiation of bones causes commonly seen causes are using oral or intravenous damage to osteocytes and impairs the blood supply. steroids, excessive alcohol use, sickle cell disease, The affected hard tissues become hypovascular radiation therapy, Gaucher disease, dislocation, or (reduced number of blood vessels), hypocellular fractures around a joint.[2] Some diseases that are (reduced number of cells), and hypoxic (low levels of associated with the development of this condition oxygen). ORN is the term for when the area of bone include gout, atherosclerosis, and diabetes. When does not heal from this damage. This usually occurs it occurs in the shoulder joint, it is usually due to a in the mandible and causes chronic pain and surface long-term treatment with steroids or a history of ulceration. Prevention of ORN is part of the reason trauma to the shoulder.[3] Persons at risk are survivors why all teeth of questionable prognosis are removed who received high doses of radiation to the jaw area. before the start of a course of radiotherapy.[1] Survivors who received radiation doses of 50 Gy or higher to the jawbone have the highest risk for the ETIOLOGY condition. Radiotherapy gives a progressive injury to tissues at a cellular and subsequently humoral level. Osteonecrosis occurs when part of the bone does If the entire dose is given in a short period of time, not get blood and dies. After a while, the bone can this will prevent the remaining viable local non-tumor collapse. If osteonecrosis is not treated, the joint cells from recovering and, therefore, will cause more deteriorates, leading to severe arthritis. Osteonecrosis damage.[3,4] can be caused by disease, or a severe trauma, such as a fracture or dislocation that affects the blood supply to PATHOGENESIS

Access this article online In simplistic terms, radiation produces its deleterious effects through the production of free radicals, which Website: jprsolutions.info ISSN: 0975-7619 result in mitotic cell death. The effects will be greatest on

1Department of Oral Medicine, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India, 2Department of Research, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India, 3Department of Pedodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India

*Corresponding author: Dr. R. Sarah Sathiyawathie, Department of Research, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, 162, Poonamallee High Road, Chennai–600 077, Tamil Nadu, India. Phone: +91-9884156513. E-mail: [email protected]

Received on: 12-09-2018; Revised on: 22-11-2018; Accepted on: 17-01-2019

1622 Drug Invention Today | Vol 11 • Issue 7 • 2019 N. C. Indhu Rekka, et al. rapidly dividing cells such as the mucosa. Remodeling beginning radiation therapy.[14] Extraction of teeth during cells such as fibroblasts, osteoblasts, and osteoclasts radiation therapy should be discouraged and delayed will show changes when they try to divide, such as until the completion of treatment with resolution of during healing.[5] Damage to the microvasculature the oral mucositis. To prevent radiation caries, patients results in initial hyperemia followed by endarteritis, should begin daily fluoride treatment with 1% neutral thrombosis, and eventual obliteration. This results in sodium fluoride gel in prefabricated trays for 5 min each hypocellularity, hypoxia, and hypovascularity.[6] day. This practice should continue for life.[15]

MANAGEMENT Treatment ORN is an unusual complication from radiation Microvascular reconstruction with its own blood therapy to the head and neck that unfortunately results supply seems to expedite bone healing and limit further in bone death. Radiation therapy is used to kill cancer ORN of the remaining mandible. Although prevention cells, but the treatment also harms healthy cells at the is the primary goal in radiation injury, our experience same time.[16] If enough of the healthy cells in your suggests that radical resection with free microvascular jawbones are damaged, it can result in a decrease of reconstruction offers significant advantages to selected blood or essential nutrients to that area.[17] Our bones [7] patients with extensive ORN of the mandible. require a constant supply of blood for nourishment and Patients diagnosed with head and neck cancer (HNC) support so if this supply is compromised; it can lead to who may need radiotherapy to the oral cavity in the the death of that section of bone.[17] Once a section of course of their cancer treatment should undergo a the jaw dies, it begins to deteriorate and weaken. Minor thorough pre-treatment dental evaluation. The dentist trauma such as dental surgery or other procedures to who completes the evaluation must have experience the head and neck may exacerbate the weakness and [4] with the management of patients with HNC. lead to further pain.[18] The jawbones can become exposed in the mouth or through the facial skin, and PREVENTIVE MEASURES the weakness may even lead to jaw fracture.[19] BEFORE RADIOTHERAPY Hyperbaric oxygen (HBO) therapy is recognized The patient should have a full dental evaluation. This as an adjunctive treatment for ORN. It may also be should include radiographs to show all the teeth as well used prophylactically in patients who require dental as the jaws to check for unerupted teeth and any bony extractions and is at high risk for developing ORN. pathology. A panoral radiograph should be a minimum, This article reviews the treatment outcomes of patients but ideally, periapical views of all the teeth should be treated with HBO. Patients who were at risk for taken.[8] All the teeth should be meticulously charted developing ORN and had tooth extractions received for caries and periodontal pocketing. Each tooth should HBO therapy with total oxygen time ranging from be given an individual prognosis and a treatment 1980 to 3390 min (6–21 pre-operative dives and 2–24 plan completed and discussed with the patient. It is post-operative dives). These patients were surveyed important to educate the patient regarding meticulous for post-operative complications.[20,21] oral hygiene and the need for lifelong regular follow- up.[9] The patient’s motivation and compliance should POST-OPERATIVE be taken into account when assessing which teeth can COMPLICATIONS be salvaged and which should be removed. All teeth should be cleaned and scaled. The patient should be Surgical management of ORN patients is challenging encouraged to rinse with a fluoride and antibacterial and complex because previous surgery and irradiation mouthwash on a regular basis, and high-risk patients result in obliterated tissue planes and higher risk for should have custom trays made to assist in regular wound healing problems, respectively.[22] In experienced fluoride treatment.[10] Patients with no teeth are easier hands, partial or total free flap loss which requires a to treat but should still have a baseline radiographic second free flap or regional myocutaneous flap may evaluation to check for buried teeth. Dentures should range from 0% to 15%. Local wound healing problems be inspected for fitting to ensure minimal trauma to resulting in dehiscence, plate exposure, or orocutaneous the tissues.[8,11,12] fistula formation may occur in 8–43%. Most of these latter complications, however, can usually be managed ROLE OF A DENTIST IN ORN successfully with conservative treatment.[23] The dentist should perform prophylaxis, periodontal CONCLUSION scaling, caries control, and fabrication of fluoride trays. Teeth that cannot be salvaged with conservative HNC patients continue to pose a challenge for endodontic therapy should be extracted.[13] Ideally, surgeons and oncologists. ORN can be a cruel blow extractions should be performed 3 weeks before to patients and their families who have already had

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