Incidence of osteoradionecrosis in patients who have undergone dental extraction prior to radiotherapy: A systematic review and meta-analysis

Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy

BACKGROUND

Osteoradionecrosis is a long-term, serious side effect of head and neck radiation therapy and is associated with significant morbidity and quality of life issues.

METHODS

This paper sought to determine consensus on the prevention and management of osteoradionecrosis by an international panel of multidisciplinary professionals expert in the management of patients with head and neck cancer using a Delphi methodology. Unique to this work is our direct inclusion of the views of patients and carers in our findings.

RESULTS

This study reached consensus on the importance of pre and post oral health assessment and education for patients with head and neck cancer. This was also noted by the patients and carers who took part in the study.

CONCLUSIONS

This work highlights the need for a standardized oral health assessment tool and multidisciplinary care of patients to prevent and manage osteoradionecrosis.

Pre-chemoradiotherapy high platelet counts predict jaw osteoradionecrosis in locally advanced nasopharyngeal carcinoma patients

INTRODUCTION

This retrospective study aimed to investigate if pretreatment platelet (PLT) levels can predict the risk of osteoradionecrosis of the jaw (ORNJ) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) who received concurrent chemoradiotherapy (CCRT).

MATERIAL &METHODS

ORNJ instances were identified from LA-NPC patients' pre- and post-CCRT oral exam records. All pretreatment PLT values were acquired on the first day of CCRT. Receiver operating characteristic curve analysis was used to determine the optimal PLT cutoff that divides patients into two subgroups with distinctive ORNJ rates. The primary outcome measure was the association between pretreatment PLT values and ORNJ incidence rates.

RESULTS

The incidence of ORNJ was 8.8 % among the 240 LA-NPC patients analyzed. The ideal pre-CCRT PLT cutoff which divided the patients into two significantly different ORNJ rate groups was 285,000 cells/µL (PLT ≤ 285,000 cells/µL (N = 175) vs. PLT > 285,000 cells/µL (N = 65)). A comparison of the two PLT groups revealed that the incidence of ORNJ was substantially higher in patients with PLT > 285,000 cells/L than in those with PLT≤285,000 cells/L (26.2% vs. 2.3 %; P < 0.001). The presence of pre-CCRT ≥3 tooth extractions, any post-CCRT tooth extractions, mean mandibular dose ≥ 34.1 Gy, mandibular V57.5 Gy ≥ 34.7 %, and post-CCRT tooth extractions > 9 months after CCRT completion were also associated with significantly increased ORNJ rates. A multivariate Cox regression analysis demonstrated that each characteristic had an independent significance on ORNJ rates after CCRT.

CONCLUSION

An affordable and easily accessible novel biomarker, PLT> 285,000 cells/L, may predict substantially higher ORNJ rates after definitive CCRT in individuals with LA-NPC.

Review of Osteoradionecrosis of the Jaw: Radiotherapy Modality, Technique, and Dose as Risk Factors

Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) is the cornerstone of organ-sparing or adjuvant therapy for nearly all head and neck cancers. Unfortunately, aggressive RT or CCRT can result in severe late toxicities, such as osteoradionecrosis of the jaws (ORNJ). The incidence of ORNJ is currently less than 5-6% due to advances in dental preventive care programs, RT planning systems, and RT techniques. Although numerous patient-, tumor-, and treatment-related factors may influence the incidence rates of ORNJ, RT modality (equipment), technique, and dose-volume-related factors are three of the most influential factors. This is mainly because different RT equipment and techniques have different levels of success at delivering the prescribed dose to the focal volume of the treatment while keeping the "organ at risk" safe. ORNJ risk is ultimately determined by mandibular dose, despite the RT technique and method being known predictors. Regardless of the photon delivery method, the radiobiological effects will be identical if the total dose, dose per fraction, and dose distribution within the tissue remain constant. Therefore, contemporary RT procedures mitigate this risk by reducing mandibular dosages rather than altering the ionizing radiation behavior in irradiated tissues. In light of the paucity of studies that have examined the impact of RT modality, technique, and dose-volume-related parameters, as well as their radiobiological bases, the present review aims to provide a comprehensive overview of the published literature on these specific issues to establish a common language among related disciplines and provide a more reliable comparison of research results.

The predictive value of pretreatment hemoglobin-to-platelet ratio on osteoradionecrosis incidence rates of locally advanced nasopharyngeal cancer patients managed with concurrent chemoradiotherapy

BACKGROUND

This retrospective study aimed to investigate whether the pretreatment hemoglobin-to-platelet ratio (HPR) could predict the risk of osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (C-CRT) for locally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

ORN cases were reported from the records of LA-NPC patients who had oral examinations before and after C-CRT. The pretreatment HPR values were calculated on the first day of C-CRT. The connection between HPR values and ORN occurrences was determined using receiver operating characteristic curve analysis. The primary endpoint was the relationship between the pretreatment HPR values and post-C-CRT ORN incidence rates, while secondary endpoints included the identification of other putative ORN risk factors.

RESULTS

We distinguished 10.9% incidences of ORN during the post-C-CRT follow-up period among 193 LA-NPC patients. The optimal cutoff for pre-C-CRT HPR was 0.48 that grouped the patients into two HPR groups with fundamentally different post-C-CRT ORN incidence rates: Group 1: HPR ≤ 0.48 (N = 60), and Group 2: HPR > 0.48 (N = 133). The comparative analysis indicated a significantly higher ORN incidence in HPR ≤ 0.48 group (30%; P < 0.001). The other factors associated with meaningfully increased ORN rates included the presence of pre-C-CRT ≥ 5 teeth extractions, mandibular volume receiving ≥ 64 Gy, post-C-CRT tooth extractions, mean mandibular dose ≥ 50.6 Gy, and C-CRT to tooth extraction interval > 5.5 months.

CONCLUSION

Low pretreatment HPR levels were independently and unequivocally linked to significantly increased incidence of ORN post-C-CRT. Pre-C-CRT HPR levels may be used to estimate the incidence of ORN and be useful for taking preventive and therapeutic measures in these patients such as monitoring oral hygiene with strict follow-up, avoidance of unnecessary tooth extractions, particularly after C-CRT, and use of more rigorous mandibular RT dose limits.

Risk factors for pathological fracture in patients with mandibular osteoradionecrosis

Osteoradionecrosis (ORN) often results in pathological fractures through progression. We aimed to identify the risk factors for pathological fracture in patients with mandibular ORN. Seventy-four patients with mandibular ORN were included in this retrospective study. We investigated various risk factors for pathological fracture in patients with mandibular ORN, including number of mandibular teeth with a poor prognosis each at initial evaluation before radiation therapy (RT) and when fracture occurred, and the proportion of antibiotic administration period in a follow-up duration after RT. The rate of occurrence of pathological fractures in patients with mandibular ORN was 25.7%. The median of duration between RT completion and fracture occurrence was 74.0 months. We found that pathological fracture was significantly associated with a larger number of mandibular teeth with a poor prognosis at initial evaluation before RT (P = 0.024) and when fracture occurred (P = 0.009). Especially, a larger number of mandibular teeth with P4 periodontitis, in other words severe periodontal status, was related to pathological fracture in both timings. The proportion of antibiotic administration period in a follow-up duration was also significant risk factor (P = 0.002). Multivariate analyses showed statistically significant associations between pathological fracture and a larger number of mandibular teeth with a poor prognosis when fracture occurred (hazard ratio 3.669). The patient with a larger number of mandibular teeth with P4 periodontitis may have a risk of not only occurrence of ORN but resulting in pathological fracture by accumulation of infection. Surgeons should consider extraction of those teeth regardless of before/after RT if necessary for infection control.

Association between tooth extraction during radiotherapy and the risk of osteoradionecrosis in patients with head and neck cancers

PURPOSE

It is commonly recommended that tooth extraction should be performed prior to radiotherapy (RT) in patients with head neck cancer to prevent osteoradionecrosis (ORN). However, doctors still occasionally encounter patients who require tooth extraction during RT. This study aimed to determine the risk of ORN in patients who undergo tooth extraction during RT.

METHODS

Data were collected from Taiwan's National Health Insurance Research Database. We retrospectively enrolled 24,412 patients with head and neck cancer treated with radiotherapy between 2011 and 2017. The associations between ORN and demographic characteristics, timing of tooth extraction, and treatments were examined using univariate and multivariable Cox proportional hazards regression models.

RESULTS

A total of 24,412 head and neck cancer patients were enrolled; 133 patients underwent tooth extraction during RT and 24,279 patients did not undergo tooth extraction during RT. Tooth extraction during RT was not associated with a significantly higher risk of ORN (hazard ratio [HR] = 1.303, P = 0.4862). Tumor site, RT dose ≥ 60 Gy, age < 55 y/o, mandibulectomy, chronic periodontitis, and chemotherapy were significantly associated with a higher risk of ORN.

CONCLUSION

The risk of ORN in head and neck cancer is not significantly different between patients who undergo tooth extraction during RT and patients who do not undergo tooth extraction during RT.

Pre-chemoradiotherapy low hemoglobin levels indicate increased osteoradionecrosis risk in locally advanced nasopharyngeal cancer patients

PURPOSE

We aimed to determine whether pretreatment hemoglobin (Hb) levels can predict the risk of osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (CCRT) for locally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

ORN cases were identified from the records of LA-NPCs who had oral exams before and after CCRT. All Hb measurements were obtained on the first day of treatment. Receiving operating characteristic curve analysis was used to determine the relationship between Hb levels and ORN rates. The relationship between pretreatment Hb levels and ORN rates served as the primary endpoint, and secondary endpoints included the discovery of additional potential ORN risk factors.

RESULTS

Among the 263 eligible LA-NPCs, we identified 8.7% ORN cases. The ideal cutoff Hb before CCRT was 10.6 g/dL. It was revealed that HPR ≤ 10.6 group had a significantly higher ORN rate (32.5% vs. 1.5% for Hb > 10.6; P < 0.001). The mandibular V59.8 ≥ 36% Gy, pre-CCRT ≥ 4 tooth extractions, the presence of post-CCRT tooth extractions, and the time of post-CCRT tooth extractions > 8 months were the other factors associated with significantly increased ORN rates (P < 0.05 for each).

CONCLUSION

Low pre-CCRT Hb levels appeared to be independently linked to significantly higher ORN rates. Pretreatment Hb levels may be used to establish preventive measures and predict ORN.

Osteonecrosis of the Jaw

Osteonecrosis of the jaw is a condition in which bone cells die due to various causes. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis. Antiresorptive or antiangiogenic drugs cause drug-induced osteonecrosis. The combination of medications, microbial contamination, and local trauma induces this condition. Osteoradionecrosis is a severe radiation therapy side effect that can affect people with head and neck cancer. It is described as an exposed bone area that does not heal for longer than three months after the end of radiation treatment with the absence of any indications of an original tumor, recurrence, or metastasis. Trauma (tooth extraction), tumor site, radiation dose that the patient receives, the area of the bone which is irradiated, oral hygiene, and other factors are risk factors for the development of osteonecrosis. Less frequently, osteonecrosis can also be induced by non-traumatic and traumatic causes. Non-traumatic osteonecrosis is brought on by infections, acquired and congenital disorders, as well as the impact of chemicals. Traumatic osteonecrosis is brought on by thermal, mechanical, or chemical damage. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient's quality of life, and surgical, which involves debridement of the necrotic bone.

Osteoradionecrosis of the Hip, a Troublesome Complication of Radiation Therapy: Case Series and Systematic Review

Background

Osteoradionecrosis of the hip is a serious complication of radiotherapy that is easily overlooked by physicians and patients in the early stages. There are relatively few reports on this subject, so there is no clear scientific consensus for the pathogenesis, early diagnosis, and clinical treatment of hip osteoradionecrosis. In this paper, we report two cases of hip osteoradionecrosis and systematically review the related literature.

Case Presentation

We report two cases of hip osteoradionecrosis. One patient successfully underwent total hip arthroplasty in our hospital and recovered well postoperatively. Another patient although we offered a variety of surgical options for this patient, the patient was worried that the bone loss would lead to poor prosthesis fixation, resulting in prosthesis loosening and infection, and therefore ultimately refused surgical treatment.

Conclusion

With the development of radiological techniques, the incidence of hip osteoradionecrosis is decreasing year by year, but early diagnosis and rational treatment remain challenging. The effects of non-surgical treatment are limited. Early prevention, early detection, and early intervention are crucial to delay or prevent the emergence of more serious complications.

Risk factors for osteoradionecrosis of the jaw in patients with head and neck squamous cell carcinoma

BACKGROUND

To evaluate factors associated with osteoradionecrosis of the jaw (ORNJ) in patients with head and neck squamous cell carcinoma (HNSCC), focusing on jaw-related dose-volume histogram (DVH) parameters.

METHODS

We retrospectively reviewed the medical records of 616 patients with HNSCC treated with curative-intent or postoperative radiation therapy (RT) during 2008-2018. Patient-related (age, sex, history of smoking or alcohol use, diabetes mellitus, performance status, pre-RT dental evaluation, pre- or post-RT tooth extraction), tumor-related (primary tumor site, T-stage, nodal status), and treatment-related (pre-RT surgery, pre-RT mandible surgery, induction or concurrent chemotherapy, RT technique) variables and DVH parameters (relative volumes of the jaw exposed to doses of 10 Gy-70 Gy [V10-70]) were investigated and compared between patients with and without ORNJ. The Mann-Whitney U test was used to compare RT dose parameters. Univariate and multivariate Cox regression analyses were used to assess factors associated with ORNJ development. Kaplan-Meier analyses were performed for cumulative ORNJ incidence estimation.

RESULTS

Forty-six patients (7.5%) developed ORNJ. The median follow-up duration was 40 (range 3-145) months. The median time to ORNJ development was 27 (range 2-127) months. DVH analysis revealed that V30-V70 values were significantly higher in patients with than in those without ORNJ. In univariate analyses, primary tumor site, pre-RT mandible surgery, post-RT tooth extraction, and V60 > 14% were identified as important factors. In multivariate analyses, V60 > 14% (p = 0.0065) and primary tumor site (p = 0.0059) remained significant. The 3-year cumulative ORNJ incidence rates were 2.5% and 8.6% in patients with V60 ≤ 14% and > 14%, respectively (p < 0.0001), and 9.3% and 1.4% in patients with oropharyngeal or oral cancer and other cancers, respectively (p < 0.0001).

CONCLUSIONS

V60 > 14% and oropharyngeal or oral cancer were found to be independent risk factors for ORNJ. These findings might be useful to minimize ORNJ incidence in HNSCC treated with curative RT.

Tumor subsites and risk of osteoradionecrosis of the jaw in patients with oral cavity cancer: a national-based cohort study

PURPOSE

The association between the tumor subsites of the oral cavity and the risk of osteoradionecrosis of the jaw (ORNJ) remains unclear. We study the correlation between oral cavity tumor subsites and the risk of ORNJ in a nationwide population-based database.

METHODS

We enrolled 16,701 adult patients with oral cavity cancers who were treated with radiotherapy between 2000 and 2013. The subsites of the oral tumor, treatments of oral cavity cancers, and the timing of tooth extraction were examined for their association with ORNJ in oral cancer patients.

RESULTS

903 patients (5.40%) developed ORNJ. Of the relevant variables, pre-RT mandible surgery, tooth extraction either before or after RT, and tumor sites were associated with the risk of ORNJ. The adjusted HRs for ORNJ in the mouth floor, gums, retromolar, and buccal cancer were 2.056 (1.490-2.837), 1.909 (1.552-2.349), 1.683 (1.105-2.562), and 1.303 (1.111-1.528), respectively, compared with the risk of tongue cancer. There was no significant difference in the risk of ORNJ between the pre-RT extraction group, the during-RT extraction group, and the post-RT extraction (less than 6 months) group; the post-RT extraction (more than 6 months) group had a significantly higher risk of ORNJ.

CONCLUSIONS

This study demonstrated that oral cavity tumor subsite is an independent risk factor of ORNJ after RT. Post-RT extraction (less than 6 months) group did not carry a significantly higher risk of ORNJ compared with pre-RT extraction group or during RT extraction group.

Oral and Dental Abnormalities Caused by a Pediatric Rhabdomyosarcoma Tumor Treatment: A Clinical Case Report

Rhabdomyosarcoma is one of the most common soft-tissue sarcomas in children. The therapy for this condition has evolved significantly over recent decades, as has survival rates. Nevertheless, multiagent chemotherapy, radiation therapy, surgical resection or a combination of these modalities still have to be performed. This case report presents a 16-year-old boy with oral and dental effects after rhabdomyosarcoma treatment, diagnosed at the age of 4 years old. This report highlights the key role of dentists in the clinical management of rhabdomyosarcoma cases before, during and after treatment, and its potential side effects.

Use of platelet-rich fibrin and surgical approach for combined treatment of osteoradionecrosis: a case report

Osteoradionecrosis (ORN) is a complication of radiation therapy for which several treatment options have been reported. The use of platelet‐rich fibrin (PRF), a second-generation platelet concentrate, has been promoted in refractory wounds. A 53-year-old man underwent concurrent chemoradiotherapy for squamous cell carcinoma in the right side of the tongue. Subsequently, he exhibited pus discharge around the right maxillary first molar. Intraoral examination showed mobility and probing depths of >10 mm in teeth 15 and 16. Computed tomography revealed poorly defined osteolytic changes in teeth 15 to 17, indicative of oroantral fistula. Teeth 15 to 17 were extracted and the socket was debrided. Primary closure was achieved after PRF dressing. The wound healed within 2 weeks. The patient returned because of spontaneous loss of tooth 46 and numbness over the right lower lip. Pus was present in premolar areas and in the tooth 46 socket. Radiographic examination showed moth-eaten destruction in right mandibular teeth and better trabecular quality in the right maxilla. A provisional diagnosis of ORN was made. Debridement and primary closure after PRF dressing were performed. The mucosa healed within 3 weeks. Our findings suggest that PRF combined with a surgical approach might be useful for treatment of ORN.

Modern management of osteoradionecrosis

PURPOSE OF REVIEW

Despite recent advances in radiotherapy, osteoradionecrosis (ORN) remains a common and difficult complication of radiation therapy in head and neck cancer patients. Available treatment options are complementary to its complex pathophysiology and the currently available theories of ORN development. The efficacy of hyperbaric oxygen therapy has recently been questioned, and therapies targeting the fibroatrophic process have become a focus of ORN treatment. The objective of this review is to evaluate the literature regarding ORN of the mandible, with a focus on available treatment options.

RECENT FINDINGS

The recently proposed fibroatrophic theory has challenged the traditional hypovascular-hypoxic-hypocellular theory as the mechanism of ORN. Medical management targeting this fibroatrophic process offers promising results, but has yet to be confirmed with robust clinical trials. The routine use of hyperbaric oxygen therapy is not substantiated in the literature, but may be justified for select patients. Systemic steroids may also have a role, though data are limited.

SUMMARY

The fibroatrophic process has gained acceptance as a main mechanism of ORN. No gold standard treatment or consensus guidelines exist, though a combination of therapeutic strategies should be considered, taking into account the severity of disease and individual patient characteristics.

Osteonecrosis of the jaws: a 14-year retrospective survey of hospital admissions

BACKGROUND

Osteonecrosis of the jaw (ONJ) is a serious complication of both radiation and antiresorptive therapies. This study aimed to determine how many patients have been treated for medication-related osteonecrosis of the jaws (MRONJ) and osteoradionecrosis (ORN), and whether the number of diagnoses has decreased over time with improved awareness and preventative measures.

METHODS

Medical records at the Royal Brisbane and Women's Hospital, Gold Coast University Hospital and Robina Hospital were reviewed to identify patients diagnosed with MRONJ and ORN between January 2003 and May 2017. Data on patient demographics, year of admission and primary disease were analysed.

RESULTS

Two hundred and thirty-eight patients were diagnosed with ONJ, of which 74.4% were ORN and 25.6% were MRONJ. Tongue (24.6%), floor of mouth (17.3%) and tonsillar (15.1%) squamous cell carcinomas were the most common primary diseases associated with ORN, with a strong male predominance (80%). Of patients diagnosed with MRONJ, 52.5% were taking low-dose antiresorptives for osteoporosis (44.2%), rheumatoid arthritis (4.6%) or Paget's disease (3.3%), while 47.5% were oncology patients receiving high-dose antiresorptives.

CONCLUSIONS

The number of patients diagnosed with MRONJ and ORN has trended upwards since 2003. ORN affected three times more patients than MRONJ, and patients on low-dose antiresorptives accounted for over half of the MRONJ cases.

Risk factors for and the role of dental extractions in osteoradionecrosis of the jaws: A national-based cohort study

BACKGROUND

The purpose of this study was to investigate the risk factors, especially the use of certain drugs and the dental procedures, for osteoradionecrosis of the jaw (ORNJ) in patients with head and neck cancer undergoing irradiation as their primary treatment.

METHODS

The cohort was composed of 23,527 patients with head and neck cancer. Cox proportional hazard models were used for risk factors analysis.

RESULTS

The overall incidence of ORNJ is 3.93 per 100 person-years. Buccal cancer carried the highest ORNJ risk. The use of steroids had a protective effect. Preradiotherapy extraction posed no excess risk, whereas postradiotherapy extraction was associated with gradually increased risk of ORNJ over time that peaked at 4 to 5 years.

CONCLUSION

ORNJ warrants life-long attention for head and neck cancer survivors. The present study strongly confirms the role of preirradiation dental extractions. Meanwhile, efforts should be made to prevent posttreatment extractions, especially in the first posttreatment 4 years. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1313-1321, 2017.