Presentation
At present, the focus is on the prevention of ORN. [contempclindent.org]
[…] front teeth present the lowest risk. [medium.com]
Results: A total of 89 patients (55 male and 34 female) underwent extractions of teeth which were present in the radiation field. [cancerjournal.net]
Initial presentation 3 moths later 41. [ffofr.org]
We present a rare case of osteoradionecrosis in the lumbar spine 25 years after radiotherapy to the pelvis for cervical cancer. Case report A 58-year-old woman presented with a two-month history of lower lumbar pain. [online.boneandjoint.org.uk]
Entire Body System
- Swelling
Decreasing swelling (edema) around the radiation site. Decreasing the swelling allows the blood to flow more freely to the area, bringing with it oxygen. [virginiamason.org]
Sub-mentally, there was an active draining fistula with no signs of facial asymmetry or swelling with no lymphadenopathy. [jofs.in]
You may experience pain, swelling and malocclusion (misalignment of the teeth). For diagnosis and treatment of this condition, seek the oral and maxillofacial surgeons at Jefferson. [hospitals.jefferson.edu]
However, when this cannot happen, the area can become repetitively infected, leading to facial swelling, pain, and necessitating courses of antibiotics. [med.stanford.edu]
I was being treated with a constant diet of antibiotics to keep the swelling down… but from time to time it was really bothersome. They could treat the swelling, but they couldn’t treat the pain.” [nolacraniofacial.com]
- Inflammation
[…] thickness cross sections of mandible to document possible disease heterogeneity Microscopic (histologic) description Microscopic features may overlap with osteomyelitis, particularly in cases with superinfection Three phases: Prefibrotic phase: chronic inflammation [pathologyoutlines.com]
A computed tomography (CT) scan revealed chronic inflammation and fibrosis involving skin and soft tissues underneath and surrounding the 2nd, 3rd, and 4th left anterior ribs. [woundsresearch.com]
C/T = chemotherapy, R/T = radiation therapy. * = patients had pathologic findings of ORN (ie, nonviable bone with chronic inflammation and fibrosis). [pubs.rsna.org]
Today, Marx’s theory on the genesis of ORN has been challenged by the fibroatrophic theory, 8 which suggests the osteocytes are damaged by free radicals from the radiation therapy, and this leads to inflammation and, thus, chronic activation of fibroblasts [decisionsindentistry.com]
The irradiated mandible, periosteum, and overlying soft tissue undergo hyperemia, inflammation, and endarteritis. These conditions ultimately lead to thrombosis, cellular death, progressive hypovascularity, and fibrosis. [emedicine.medscape.com]
- Weakness
The jaw bones can become exposed in the mouth or through the facial skin and the weakness may even lead to jaw fracture. [ucsfhealth.org]
Based on weak evidence, prophylactic hyperbaric oxygen is effective in reducing the risk of developing osteoradionecrosis after post-radiation extractions. Copyright © 2010 International Association of Oral and Maxillofacial Surgeons. [scienceopen.com]
There was, however, an appreciable weakness of the marginal mandibular branch of the facial nerve ( Figure 7 ). [omicsonline.org]
[…] by myofibroblasts coupled with decreased production of osteoid by osteoblasts results in weakened bony tissue. [19] Finally, during the late fibroatrophic phase, the affected bone becomes hypocellular as myofibroblasts begin to die and leave behind weak [en.wikipedia.org]
They concluded, based on weak evidence, that prophylactic HBO therapy was effective in reducing the risk of developing ORN after post‐radiation extractions. [cochranelibrary.com]
- Lymphadenopathy
Sub-mentally, there was an active draining fistula with no signs of facial asymmetry or swelling with no lymphadenopathy. [jofs.in]
Enlarged cervical lymphadenopathy was seen more often in the recurrence group ( P < .01). [pubs.rsna.org]
[…] early indicator may be paraesthesia or numbness of the lip or other area of the mouth such as; Pain Swelling Non-healing sore or ulcer in the mouth Trismus An extra-oral fistula (from jaw to skin) Infection in gums/teeth Extra-oral draining sinuses Lymphadenopathy [en.wikipedia.org]
- Fever
Clinical history of current dental issues Subjective history of pain/swelling/fever/temperature sensitivity/oral fetor Clinical examination Radiographic examination If it is determined that the source of infection or rampant decay was in the field of [oasisdiscussions.ca]
[…] periods of exacerbations and remissions over many years Characterized by an inflammatory process presenting with findings similar to infectious osteomyelitis; however, no infectious source is identifiable Characterized by insidious onset of low grade fever [pathologyoutlines.com]
Infectious symptoms (fever, pus, otorrhea) were noted only in the ORN group ( n = 3, 15%), whereas palpable masses occurred only in the recurrence group ( n = 3, 20%). [pubs.rsna.org]
Jaw & Teeth
- Trismus
[…] tissue disorders 10044684 Trismus PT 20.0 10017947 - Gastrointestinal disorders 10013950 Dysphagia PT Population Age: Adults, Elderly Gender: Male, Female Trial protocol: GB (Ongoing) Trial results: (No results available) EudraCT Number: 2015-000618- [clinicaltrialsregister.eu]
Pain, trismus, difficulty with speech and eating, and a malodorous wound are all problems that must be corrected. [jamanetwork.com]
Findings Final dx ORN (# of patients) Final dx SCC (# of patients) Trismus 4 4 Oral pain 3 5 Exposed bone 4 5 Soft tissue enhancement on CT 6 6 Bone sclerosis on CT 3 3 [ascopubs.org]
Noted but not measurable Preventing normal eating Difficulty eating Inadequate oral intake OBJECTIVE Exposed Bone ≤ 2 cm > 2 cm or limited sequestration Fracture Trismus 1 to 2 cm opening 0.5 to 1 cm opening < 0.5 cm opening MANAGEMENT Pain Occasional [cochranelibrary.com]
It is believed that the reparative capacity of radiation-injured bone is exceeded Clinical presentation: pain, swelling, trismus, exposed bone, pathologic fracture, malocclusion, oral cutaneous fistula formation Grading Grade I: exposed alveolar bone [en.wikibooks.org]
- Xerostomia
Ocular, and Maxillofacial Prosthetics Group, provided a preliminary response to this question: With the numerous comorbidities associated with head and neck radiation (oral mucositis, radiodermatitis, dysgeusia, dysphagia/odynophagia, trismus, and xerostomia [oasisdiscussions.ca]
These include loss of facial hair growth, profound xerostomia (dry mouth), tissue induration, and taste loss. Patients sometimes experience mucosal telangiectasia, characterized by small dilated blood vessels along the mucosa inside the mouth. [medium.com]
The presence of xerostomia, dysphagia, dysphonia, and ageusia should be noted. Evaluation Imaging such as radiographs, panorax images, CT, MRI should be reviewed. There are no lab studies that are diagnostic for ORN per se other than biopsy. [statpearls.com]
Xerostomia induced by radiotherapy: an overview of the physiopathology, clinical evidence, and management of the oral damage. Ther Clin Risk Manag. 11: 171 – 188. Google Scholar Reuther, T, Schuster, T, Mende, U, Kübler, A. 2003. [journals.sagepub.com]
With advancement of the conditions can lead to pathologic fracture, intra/extra oral fistula, infections, pain, xerostomia, halitosis and food impactions (3). [biomedpharmajournal.org]
- Bruxism
[…] marrow defect Paget's disease of bone Periapical abscess Phoenix abscess Periapical periodontitis Stafne defect Torus mandibularis Temporomandibular joints, muscles of mastication and malocclusions – Jaw joints, chewing muscles and bite abnormalities Bruxism [en.wikipedia.org]
- Jaw Pain
Symptoms include: Limited range of motion of jaw Pain that occurs at rest Jaw or facial swelling Exposure of the mandible or maxilla, which are the upper and lower jaw You will be diagnosed with osteoradionecrosis by an oral and maxillofacial or head [ucsfhealth.org]
Cardiovascular
- Thrombosis
Osteoradionecrosis may lead to chronic otomastoiditis, meningitis, lateral sinus thrombosis, and intracranial abscess. [insights.ovid.com]
These conditions ultimately lead to thrombosis, cellular death, progressive hypovascularity, and fibrosis. The radiated bed is hypocellular and devoid of fibroblasts, osteoblasts, and undifferentiated osteocompetent cells. [emedicine.medscape.com]
[…] respond to HBO Grade III: full-thickness involvement and/or pathologic fracture On pathology, inferior alveolar artery (the predominant arterial blood supply to the body of the mandible) and periosteal arteries have significant intimal fibrosis and thrombosis [en.wikibooks.org]
Also the patient’s past history of smoking had resulted in microvascular thrombosis. [omicsonline.org]
The effects of radiation on the tissue level are endothelial necrosis, hyalinization, and thrombosis of vessels. The periosteum becomes fibrotic and bone osteoblasts and osteocytes undergo death with fibrosis of the marrow spaces. [newyorkpersonalinjuryattorneysblog.com]
- Vascular Disease
Patients were deemed medically compromised if they had peripheral vascular disease or diabetes. HBO treatments were delivered at the Hyperbaric Oxygen Unit at the Toronto General Hospital. [cda-adc.ca]
Skin
- Ulcer
Early ulceration results from epidermal necrosis, while deeper ulcers due to dermal ischemia tend to present years after exposure. [woundsresearch.com]
[osteo- + radionecrosis] osteoradionecrosis Degenerative pathology caused by radiation-induced cell injury, resulting in ↓ cell repair, ↓ vascularity, local hypoxia, necrosis, defective wound healing Clinical Edema, ulceration, bone necrosis, poor wound [medical-dictionary.thefreedictionary.com]
Patient presented with deep pharyngeal ulcer, spondylitis of C2, and spinal instability. [pubs.rsna.org]
Onset/duration ORN develops most commonly after local trauma, such as dental extractions, biopsies, related cancer surgery, periodontal procedures, and even mouth ulcers, but it may also occur spontaneously. [eviq.org.au]
Clinical signs • Ulceration and/or necrosis of the oral mucosa • Exposure of underlying bone • Malodor • In advanced stages • Ulceration of overlying skin • Pathologic fracture 7. Hypotheses for the development of ORN 1. [slideshare.net]
- Erythema
During the first phase, edema and erythema occur at 24–72 hours post exposure. Within 10 days, the second phase occurs, manifested by increased erythema and edema resolving in four weeks. [woundsresearch.com]
Epulis Pyogenic granuloma Congenital epulis Gingival enlargement Gingival cyst of the adult Gingival cyst of the newborn Gingivitis Desquamative Granulomatous Plasma cell Hereditary gingival fibromatosis Hypercementosis Hypocementosis Linear gingival erythema [en.wikipedia.org]
Musculoskeletal
- Osteoporosis
High cholesterol diet increases osteoporosis risk via inhibiting bone formation in rats. Acta Pharmacol Sin. 32(12): 1498 – 1504. Google Scholar | Crossref | Medline | ISI [journals.sagepub.com]
Pentoxifylline and tocopherol in the treatment of yearly zoledronic acid-related osteonecrosis of the jaw in a corticosteroid-induced osteoporosis. J Oral Maxillofac Surg. 2014 Feb;72(2):334-7. doi: 10.1016/j.joms.2013.06.188. [bjcasereports.com.br]
Eight patients had malignant disease and were treated with high-dose anti-resorptive drugs; seven patients with osteoporosis were treated with low-dose anti-resorptive drugs. The mean duration of high-dose anti-resorptive drug treatment was 34 months [slideshare.net]
"Bisphosphonates for the prevention and treatment of osteoporosis". BMJ. 351 : h3783. doi : 10.1136/bmj.h3783. PMID 26333528. ^ Turner AJ, Hick PE (September 1975). "Inhibition of aldehyde reductase by acidic metabolites of the biogenic amines". [en.wikipedia.org]
Surgical intervention or resection Exposed Bone Antibiotics Debridement, HBO therapy Resection Trismus & Mastication Soft diet Liquid diet, antibiotics, muscle relaxants NG tube, gastrostomy ANALYTIC Mandibular Radiograph Questionable changes or none Osteoporosis [cochranelibrary.com]
Workup
Signs and symptoms These include the following: Pain Swelling Trismus Exposed bone Pathologic fracture Malocclusion Workup Plain radiography of the mandible, or Panorex, depicts areas of local decalcification, osteolysis or sclerosis. [emedicine.medscape.com]
So, after the routine workup, the patient was taken up for Segmental mandibular resection followed by reconstruction under General anesthesia, without HBOT. [omicsonline.org]
Treatment
OsteoradionecrosisGoal of treatment – Resolution with maintenance of mandibular continuityPredictors of treatment outcomes vDose and Treatment Volume vThe higher the dose and the larger the treatment volume the less predictable the outcome. 48. [ffofr.org]
Patients are treated with 30 hyperbaric treatments preoperatively followed by bony debridement. Postoperatively they are given an additional ten treatments. [statpearls.com]
Treatment outcomes are illustrated in Table 3. [cda-adc.ca]
[…] bone exposure require more radical treatment. [arquivosdeorl.org.br]
Prognosis
[…] in a mixed sclerotic-lucent pattern sequestration, especially of the buccal bone an absence of soft tissue mass is an important feature to differentiate it from neoplastic recurrence but the presence of soft tissue does not exclude ORN Treatment and prognosis [radiopaedia.org]
However, it is crucial to distinguish between ORN, a benign condition that is managed conservatively, and recurrent SCC, which carries a poor prognosis even with treatment. [ascopubs.org]
Patients are explained to regarding the importance of good oral hygiene maintenance, the need for the removal of teeth with poor prognosis, the complications of RT, and post-RT oral care. RT is initiated only after dental clearance. [contempclindent.org]
With a better understanding of the pathophysiology of ORN, new treatments and possibilities for the most predictable results of this difficult prognosis pathology arise. [bjcasereports.com.br]
Prognosis Patients originally treated with antibiotics, hyperbaric oxygen therapy, and surgical debridement generally experienced a favorable clinical outcome. [ncbi.nlm.nih.gov]
Etiology
Osteoradionecrosis of mandible: Etiology, prevention, diagnosis and treatment. Indian J Plast Surg. 2007; 40 :s65–71. [ Google Scholar ] 4. Jacobson AS, Buchbinder D, Hu K, Urken ML. [ncbi.nlm.nih.gov]
The etiology of osteoradionecrosis is considered to be multifactorial. These factors may increase the risk of the patient for development of osteoradionecrosis. [jdrr.org]
Etiology ORN can be either spontaneous or the result of an insult. Spontaneous ORN occurs when, in the process of otherwise normal turnover of bone, the degradative function exceeds new bone production. [emedicine.medscape.com]
It is critical that all necrotic bone be debrided and removed in stage III patients. stage III osteoradionecrosis patients receive 30 treatments preoperatively followed by ten hyperbaric oxygen treatments, postoperatively. [3] Etiology Osteoradionecrosis [statpearls.com]
Epidemiology
Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review. Int Dent J. 2018 Feb;68(1):22-30. [PMC free article: PMC9378891] [PubMed: 28649774] [ncbi.nlm.nih.gov]
Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review. Int. Dent. J. 2018; 68 (1): 22-30. Epstein J, Wong F, SMP. [revoncologia.sld.cu]
Osteoradionecrosis is rarely seen in patients who received less than 6000 centiGrays (cGy) of radiation and can occur years to decades after radiation is concluded. [4] [5] Epidemiology Osteoradionecrosis occurs in approximately 9% of patients who receive [statpearls.com]
[…] and Etiology [ edit ] Epidemiology [ edit ] The epidemiology of osteoradionecrosis has proven difficult to estimate, with previous studies reporting incidence of disease between 4.74-37.5%. [6] More recent reports have estimated the incidence to 2%, [en.wikipedia.org]
Pathophysiology
The factors are classified into four groups as shown in [Table 4]. [15], [16], [17], [18] Pathophysiology The pathophysiology of osteoradionecrosis is not very clear till date. [jdrr.org]
During early post-treatment period, patient should visit the dentist every 4 months.[ 3, 4 ] Pathophysiology Since, the first description of ORN was published in 1922 several hypothetical pathologic models have been proposed. [ncbi.nlm.nih.gov]
With a better understanding of the pathophysiology of ORN, new treatments and possibilities for the most predictable results of this difficult prognosis pathology arise. [bjcasereports.com.br]
Pathophysiology Osteoradionecrosis is a delayed injury to an irradiated bone, where the bone becomes devitalised and exposed through a wound in the overlying skin or mucosa, with this wound not healing for 3-6 months. r Incidence/prevalence Incidence [eviq.org.au]
PATHOPHYSIOLOGY Bones are resistant to ORN as long as there is healthy, intact soft tissue. [decisionsindentistry.com]
Prevention
Part II: Prevention. Br J Oral Maxillofac Surg 2011;49:9-13. 21. Vudiniabola S, Pirone C, Williamson J, Goss AN. Hyperbaric oxygen in the prevention of osteoradionecrosis of the jaws. Aust Dent J 1999;44:243-7. 22. Chuang SK. [cancerjournal.net]
Reviews: 2006 PMID 16458773 — "Osteoradionecrosis prevention myths." Wahl MH et al. Int J Radiat Oncol Biol Phys. 2006 Mar 1;64(3):661-9. [en.wikibooks.org]
We will use stem cells and animal systems to understand mechanisms promoting jaw necrosis and how to prevent them. The goal is to improve quality of life of cancer survivors. [grantome.com]
Hyperbaric oxygen for the prevention of osteoradionecrosis. Information available online at http://www.isrctn.com/ISRCTN39634732 (accessed January 2017). [nature.com]
Osteoradionecrosis is difficult to prevent and treat. [en.wikipedia.org]