New perspectives on the conservative management of osteoradionecrosis of the mandible: A literature review

Abstract

Over the last decades, several therapeutic options were considered in the treatment of the osteoradionecrosis (ORN) of the mandible, including supportive measures, ultrasound therapy, corticosteroids, hyperbaric oxygen, surgical resection with reconstruction, and, more recently, drugs capable of reversing the fibroatrophic process. Once established, the ORN does not spontaneously disappear and a standard treatment has not yet been defined. The clear clinical effectiveness of hyperbaric oxygen therapy (HBOT) varies according to the literature and there are some economic/logistic issues to be considered; the triplet tocopherol/pentoxifylline/clodronate demands greater evidence from randomized clinical trials and also resilience from the patient, given the long treatment duration and its possible side effects. Controversy around the ideal treatment of the initial stage ORN of the mandible persists. More rigorous randomized prospective trials are essential. The purpose of this article was to review the relevant literature on the physiopathology of ORN of the mandible and discuss the new perspectives of its conservative treatment. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Role of surgery in the treatment of osteoradionecrosis and its complications after radiotherapy for nasopharyngeal carcinoma

“…In advanced cases, CSF leakage can develop presenting as otorrhea or pneumocephalus . Chuang et al reported on 10 patients with brain abscess after undergoing irradiation and the mortality rate was up to 30%.…”

“…In our series, a significant proportion of patients remained asymptomatic despite the presence of radiological evidence of ORN. There is no high-level evidence regarding the optimal management of early ORN, 23 and the role of hyperbaric oxygen in preventing or treating ORN is still subjected to debate. 24,25 More recently, pentoxifylline, tocopherol, and clodronate received much attention in the treatment of ORN after radiotherapy.…”

Treatment of late sequelae after radiotherapy for head and neck cancer

“…The favorable clinical outcome and the toxicity profile of the medical ORN treatment were duplicated by the same group in a larger prospective cohort of 54 HNC patients with refractory mandibular ORN, mainly after surgery and HBOT [155], and was confirmed by several other groups [152,156,157]. However, the true value of this strategy is yet to be confirmed in a randomized clinical trial setting [151]. …”

“…Wide variability in HBOT regimens used in the UK and Europe concerning the actual pressure, duration and number of dives was reported [148,149]. To overcome these shortcomings, the role of HBOT in the prevention and treatment of ORN is currently being investigated in three prospective multicenter randomized trials: the UK’s HOPON trial, the Danish DAHNCA21 trial, and the Portuguese phase II trial on HBOT therapy with or without antifibrotic agents [150,151]. …”

Oral Side Effects of Head and Neck Irradiation

“…Conservative treatment should be the first line therapy for ORN because surgical procedure may enhance the necrotic process [23]. Treatment consists of local wound care and good oral hygiene using 0.2% chlorhexidine mouthwashes and course of systemic antibiotics in acute episodes [80,81]. If a conservative Oral care after head and neck radiotherapy…”