Osteoradionecrosis of the jaw: A mini review

Abstract

Osteoradionecrosis (ORN) of the jaw is one of the most dreaded complications of head and neck radiation therapy. Despite the evolution of radiation treatment modalities, ORN continues to remain a therapeutic challenge and its etiopathogenesis still remains unclear. It is clinically characterized by exposed necrotic bone within the head and neck radiation field. Over the past years, several studies have reported on the definition, staging, incidence, etiology, and management of this oral complication. In this review, we summarize the literature on ORN and discuss our institutional experience and management strategies that aim to predict and mitigate risk for ORN.

Keywords: head and neck cancer; intensity modulated radiation therapy (IMRT); oral complications of cancer therapy; osteoradionecrosis (ORN); osteoradionecrosis of jaw.

Figure 1

A 57-year-old male patient, diagnosed with HPV positive T2N2c squamous cell carcinoma of left base of the tongue and treated with definitive chemoradiation (6996cGy in 33 fractions), developed a spontaneous exposed bone measuring 1.5 × 0.5 cm in the lingual posterior mandible adjacent to right mandibular first and second molars, consistent with Notani Stage II ORN. The exposed bony edges were sharp causing irritation to adjacent soft tissues.

Figure 2

(A) A 55-year-old- male patient, diagnosed with HPV positive T2N2M1 squamous cell carcinoma of left palatine tonsil and treated with concurrent chemoradiation (6996cGy in 33 fractions), reported to our Dental Service for opinion and management of grossly decayed left mandibular posterior teeth. (B) CT slide with 5 different teeth regions contoured in the mandible. (C) Dose volume histogram depicting maximum and mean radiation dose to 10 different teeth region in the maxilla and mandible. (D) Mean and maximum dose to the different teeth regions are mapped on to the patient's panoramic radiograph. Teeth-bearing regions with prescribed dose = above 5000Gy are considered at increased risk for ORN. For example, the ipsilateral mandibular left molar region had prescribed mean and maximum doses of 6030cGy and 7438cGy, respectively. Thus, this region is believed to be at high risk for development of ORN. Our recommended treatment included endodontic therapy of tooth # 17 followed by crown amputation and maintenance of tooth #18 to allow self-exfoliation.