Table of contents
Osteoradionecrosis of the jaw
What's new
Added 2024 ISOO/MASCC/ASCO guidelines for the diagnosis and management of osteoradionecrosis of the jaw.
Background
Overview
Definition
ORNJ is a complication of radiation therapy for head and neck, characterized by necrosis of the maxilla or mandible.
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Pathophysiology
The pathophysiology involves radiation-induced damage to the blood vessels and bone cells in the jaw, leading to tissue hypoxia and impaired healing that ultimately results in necrosis of the bone tissue.
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Epidemiology
The prevalence of osteoradionecrosis varies widely in the literature, ranging from 0.4% to 56% after radiotherapy, with a significant reduction in the modern era.
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Risk factors
Risk factors for osteoradionecrosis include high doses of radiation, poor oral hygiene and periodontal status, and dental extractions after radiotherapy. Alcohol use and smoking may also increase the risk.
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Disease course
The clinical course of osteoradionecrosis usually starts with pain, swelling, dysesthesia, and exposed bone in the mouth. As the condition progresses, complications can arise, including dysphagia, dysarthria, pathological fractures, fistula formation, and in severe cases, extra-mandibular osteoradionecrosis.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of osteoradionecrosis of the jaw are prepared by our editorial team based on guidelines from the Multinational Association of Supportive Care in Cancer (MASCC/ISOO/ASCO 2024).
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Screening and diagnosis
Diagnosis
As per ASCO/ISOO/MASCC 2024 guidelines:
Characterize ORNJ as a radiographic lytic or mixed sclerotic lesion of bone and/or visibly exposed bone and/or bone probed through a periodontal pocket or fistula, occurring within an anatomical site previously exposed to a therapeutic dose of head and neck radiotherapy.
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View patients with a radiation dose to the jaw ≥ 50 Gy as at risk for developing osteoradionecrosis. Recognize that modifiable risk factors include poor oral hygiene, dentoalveolar surgeries, and tobacco use that further increase this lifelong risk.
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Diagnostic investigations
Initial evaluation: as per ASCO/ISOO/MASCC 2024 guidelines, obtain one or more of the following in the initial evaluation of osteoradionecrosis:
clinical intraoral examination, including direct visual or endoscopic examination and/or formal periodontal assessment
formal radiographic examination (X-ray orthopanogram, cone-beam or fan-beam CT, MRI).
B
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Medical management
Pentoxifylline: as per ASCO/ISOO/MASCC 2024 guidelines, consider offering pentoxifylline in cancer-free patients with mild, moderate, or severe osteoradionecrosis. Recognize that pentoxifylline is most likely to have a beneficial effect when combined with tocopherol, antibiotics, and prednisolone.
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Therapeutic procedures
Surgical interventions
Indications for surgery, partial-thickness osteoradionecrosis: as per ASCO/ISOO/MASCC 2024 guidelines, perform a transoral minor intervention, such as debridement, sequestrectomy, alveolectomy, or soft tissue flap closure, in patients with partial-thickness osteoradionecrosis (ClinRad stage I or II).
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Indications for surgery (full-thickness osteoradionecrosis)
Preventative measures
Reduction of radiation dose: as per ASCO/ISOO/MASCC 2024 guidelines, do not compromise tumor coverage to avoid bone dose.
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Dental care (assessment)
Dental care (invasive dental procedures)
Dental care (periprocedural management)
Follow-up and surveillance
Follow-up: as per ASCO/ISOO/MASCC 2024 guidelines, obtain serial characterization or surveillance of osteoradionecrosis, including clinical intraoral examination (direct visual, endoscopic examination, and/or comprehensive periodontal assessment) and comprehensive radiographic examination (X-ray orthopanogram, cone-beam or fan-beam CT, MRI).
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