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Peterson DE, Koyfman SA, Yarom N, Lynggaard CD, Ismaila N, Forner LE, Fuller CD, Mowery YM, Murphy BA, Watson E, Yang DH, Alajbeg I, Bossi P, Fritz M, Futran ND, Gelblum DY, King E, Ruggiero S, Smith DK, Villa A, Wu JS, Saunders D. Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline. J Clin Oncol 2024; 42:1975-1996. [PMID: 38691821 DOI: 10.1200/jco.23.02750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/22/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer. METHODS The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008. RESULTS A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation. RECOMMENDATIONS Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | - Noam Yarom
- Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Charlotte Duch Lynggaard
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Lone E Forner
- Department of Oral and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
| | | | - Yvonne M Mowery
- UPMC Hillman Cancer Center, Pittsburgh, PA
- University of Pittsburgh, Pittsburgh, PA
| | | | - Erin Watson
- Department of Dental Oncology, Princess Margaret Cancer Center/Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - David H Yang
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Ivan Alajbeg
- University of Zagreb School of Dental Medicine, Zagreb, Croatia
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Neal D Futran
- University of Washington School of Medicine, Seattle, WA
| | | | - Edward King
- Northern Colorado Head and Neck Cancer Support Group, Windsor, CO
| | - Salvatore Ruggiero
- New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | | | - Jonn S Wu
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Deborah Saunders
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Ontario, Canada
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Owosho AA, DeColibus KA, Okhuaihesuyi O, Levy LC. Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series. Dent J (Basel) 2024; 12:83. [PMID: 38667995 PMCID: PMC11049290 DOI: 10.3390/dj12040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.
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Affiliation(s)
- Adepitan A. Owosho
- Department of Diagnostic Sciences, College of Dentistry/Department of Otolaryngology—Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, 875 Union Avenue, Memphis, TN 38163, USA
| | - Katherine A. DeColibus
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Osariemen Okhuaihesuyi
- Missouri School of Dentistry and Oral Health, A.T. Still University, Kirksville, MO 63501, USA
| | - Layne C. Levy
- Advanced Education in General Dentistry, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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Quah B, Yong CW, Lai CWM, Islam I. Efficacy of adjunctive modalities during tooth extraction for the prevention of osteoradionecrosis: A systematic review and meta-analysis. Oral Dis 2024. [PMID: 38396363 DOI: 10.1111/odi.14902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/18/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Jaw osteoradionecrosis (ORN) is a complication in patients with previous head and neck radiotherapy. Its incidence increases with dental extractions. Hence, this review aimed to evaluate the efficacy of adjunctive treatment modalities undertaken at the time of extraction in previous head and neck radiotherapy patients in preventing ORN. METHODS A systematic review was conducted, where studies with data on ORN incidence after extraction with or without adjunctive interventions were included. Meta-analyses were conducted to estimate the pooled prevalence of ORN per intervention and the pooled odds ratio for incidence of ORN between interventions. RESULTS In total, 1520 patients in 29 studies were included. Interventions identified were hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. The pooled prevalence of ORN for HBO (4.6%), PENTO (3.4%) and ABX (3.8%) was significantly lower than the Control (17.6%). For studies with direct comparisons between groups, HBO had lower but not significant odds of developing ORN than the Control (OR 0.27) and ABX (OR 0.57). CONCLUSIONS HBO, PENTO and ABX may reduce the incidence of ORN compared to no intervention. Given that all three have similar incidences of ORN, ABX may be the most cost-effective and accessible adjunctive modality.
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Affiliation(s)
- Bernadette Quah
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Chee Weng Yong
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Clement Wei Ming Lai
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Intekhab Islam
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
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Patel V, Young H, Mellor A, Sproat C, Kwok J, Cape A, Mahendran K. The use of liquid formulation pentoxifylline and vitamin E in both established and as a prophylaxis for dental extractions "at risk" of osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:404-409. [PMID: 37316424 DOI: 10.1016/j.oooo.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/08/2023] [Accepted: 02/19/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Osteoradionecrosis (ORN) of the jaws remains one of the most debilitating complications of radiotherapy (RT) in patients with head and neck cancer (HNC). Liquid pentoxifylline and vitamin E (PVe) presents an alternative formulation to tablets for patients with dysphagia or enteric feeding. OBJECTIVE This study aimed to assess the clinical outcomes of using a liquid formulation of PVe for both established ORN and as a prophylaxis to avoid its occurrence after dental extractions. A secondary objective was to determine patient-reported side effects in relation to the liquid formulation of PVe. STUDY DESIGN The clinical records of 111 patients with HNC who were prescribed liquid PVe were reviewed retrospectively (66 with established ORN and 45 as prophylaxis before an invasive dental procedure). RESULTS In established ORN, 44% healed, and 41% were stable. In the prophylaxis group, 96% of surgical sites healed completely, with 4% (n = 2) developing ORN. Most patients (89%) were able to tolerate liquid PVe. Of the 11% (n = 12) who could not tolerate this regime, the most commonly reported side effect was gastric irritation (n = 5/12), whereas no more than 1 patient reported dizziness, malaise, and bleeding. CONCLUSIONS This retrospective review suggests that liquid PVe is efficacious for both established ORN and as a prophylaxis. Side effects reported were similar to those recognized for the tablet formulation.
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Affiliation(s)
- Vinod Patel
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Helen Young
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Amy Mellor
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Chris Sproat
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jerry Kwok
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Angela Cape
- King's College London, London, United Kingdom
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Paiva GLA, de Campos WG, Rocha AC, Júnior CAL, Migliorati CA, Dos Santos Silva AR. Can the prophylactic use of pentoxifylline and tocopherol before dental extractions prevent osteoradionecrosis? A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:33-41. [PMID: 36882364 DOI: 10.1016/j.oooo.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Abstract
PURPOSE This systematic review aimed to determine whether the pentoxifylline and tocopherol (PENTO) protocol effectively reduce the risk of osteoradionecrosis (ORN) in patients undergoing tooth extraction after head and neck radiotherapy. METHODS We searched PubMed, SCOPUS, LILACS, EMBASE, Web of Science, and Cochrane databases up to August 2022. We considered only studies that included patients diagnosed with head and neck cancer undergoing tooth extraction with PENTO prophylaxis after radiotherapy. RESULTS Of the 642 studies identified, 4 were included. Across the included studies, 387 patients had 1871 teeth extracted while on PENTO prophylaxis. The interval of the PENTO protocol differed among the studies included. Overall, a total of 12 (3.1%) patients had ORN, whereas at the individual tooth level analysis the ORN rate was 0.9%. CONCLUSIONS Insufficient evidence exists to promote using the PENTO protocol before dental extractions to prevent ORN.
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Affiliation(s)
| | | | - André Caroli Rocha
- Department of Oral and Maxillofacial Surgery, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | | | - Cesar Augusto Migliorati
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, USA
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Patel V, Kwok J, Burke M, Urbano TG, Fenlon M. Should the HPV positive oropharyngeal cancer patient be considered for a two-stage dental assessment for their radiation treatment? Radiother Oncol 2021; 164:232-235. [PMID: 34624407 DOI: 10.1016/j.radonc.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Patients due to commence head and neck radiation treatment are expected to undergo a dental assessment and be deemed 'dentally fit'. Though this intervention is welcomed by the dental fraternity it is not without its challenges especially in human papilloma virus (HPV) related oropharyngeal cancer (OPC) which has seen a phenomenal rise over the past decade. This perspective piece presents these challenges and proposes a potential adaption of the dental assessment for HPV OPC patients though not necessarily exclusive to this tumour sub-site.
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Affiliation(s)
- Vinod Patel
- Guy's & St Thomas' Hospital Oral Surgery Dept, London, UK.
| | - Jerry Kwok
- Guy's & St Thomas' Hospital Oral Surgery Dept, London, UK.
| | - Mary Burke
- Guy's & St Thomas' Hospital Sedation & Special Care Dept, London, UK.
| | - Teresa Guerrero Urbano
- Guy's & St Thomas' NHS Trust and King's College London, Oncology Department, London, UK.
| | - Michael Fenlon
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK.
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