Fluorescence-guided surgery for osteoradionecrosis of the jaw: a retrospective study

OBJECTIVE

Osteoradionecrosis of the jaw (ORNJ) is one of the most severe head and neck complications in patients treated with radiotherapy. The goal of treatment is to suppress ORNJ progression. Currently, surgical removal of necrotic bone is an effective management approach for advanced stages. In this study, we present our experience in managing ORNJ using fluorescence-guided surgery.

METHODS

Nineteen ORNJ lesions in 15 hospitalized patients were treated with fluorescence-guided surgery. We retrospectively reviewed patients' demographic data, comorbidities, local preceding event, location, ORNJ stage, and treatment outcomes with a median follow-up of 12 months.

RESULTS

Twelve lesions (63%) were treated surgically under tetracycline fluorescence, and seven lesions (37%) were surgically treated under auto-fluorescence. Overall, four lesions (21%) achieved complete mucosal healing, eight lesions (42%) showed partial mucosal healing with bone exposure and no signs or symptoms of inflammation, and seven lesions (37%) were progressive. The results showed that either healing or ORNJ stabilization was achieved in 63% of lesions (n = 12).

CONCLUSION

Fluorescence-guided surgery can be beneficial in curing or stabilizing ORNJ. However, randomized clinical trials are needed to confirm these findings.

Outcomes of Clinical Trials on Osteonecrosis of the Jaw

Objective: The purpose of this study was to provide a cross-sectional view of all registered clinical trials enrolling patients with osteonecrosis of the jaw (ONJ). The primary aim was to report predictors of trial completion and publication of results.

Materials and Methods: This is a cross-sectional study of ONJ trials registered with ClinicalTrials.gov. For each included entry, trial characteristics and endpoints were recorded. Predictors were enrollment size, etiology, study type, intervention type, sponsor, funding, study locations, number of centers, and specialty of the principal investigator. Outcomes were trial status, publication on PubMed, journal of publication, and length of time between endpoints. Associations between predictors and outcomes were evaluated using chi-square tests and t-tests.

Results: The final sample included 26 trials. Overall, 50% of trials were completed and 69% of completed trials were published. Three out of four terminated trials were suspended due to lack of funding. The median enrollment for completed trials was 149 participants with a mean length of five years. All trials included medication-related osteonecrosis of the jaw (MRONJ) patients and 26% also included osteoradionecrosis of the jaw (ORNJ) patients. The majority of trials were observational (65%), conducted internationally (62%), and involved multiple centers (54%). Published trials had a mean time of 5.9 years between trial start and publication, which was comparable to trial length (p=0.90) and appeared in either dental (44%) or cancer (56%) journals. Completion and publication rates were not significantly increased by industry sponsorship/funding, larger enrollment sizes, or multi-center involvement. Oral and maxillofacial surgery was the most represented dental specialty of principal investigators (56%).

Conclusions: The majority of completed ONJ trials had their results published in a timely manner. Evidence-based investigation of ONJ is a multi-disciplinary and international effort. Among all specialists, oral and maxillofacial surgeons led the most ONJ trials.

Bacterial spectrum analysis and antimicrobial susceptibility study of osteoradionecrosis of the jaw in Southern China

OBJECTIVE

Osteoradionecrosis of the jaw (ORNJ) is one of the most common and serious complications after radiotherapy of head and neck malignancies due to the high incidence of nasopharyngeal cancer in Southern China. Clinicians lack understanding and consensus on anti-infective treatment in ORNJ lesions. This research aims to provide evidence for rational use of antibiotics by reviewing the bacterial spectrums and antimicrobial susceptibility test of ORNJ patients.

METHODS

We collected patient who was diagnosed with ORNJ from November 2012 to June 2019 in our hospital. Exudate or bone unexposed wound surface sampling, agar plates culturing, and susceptibility testing were analyzed. Descriptive statistics were used for data presentation.

RESULTS

A total of 219 samples were collected in our retrospective study. The most common cultured bacteria were Klebsiella pneumoniae (15.10%), Pseudomonas aeruginosa (13.54%), and Staphylococcus aureus (10.94%). Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 5.21% in the whole positive samples. Ticarcillin, Ofloxacin, Vancomycin, Tigecycline, and Meropenem were more susceptible than other antibiotics to treat uncontrollable infection.

CONCLUSIONS

Our research provided objective evidence for understanding the types of local bacterial flora and drug susceptibility in ORNJ lesions and gave a guiding reference for empirical antibiotics medication.

Is the Risk to Develop Osteoradionecrosis of the Jaws Following IMRT for Head and Neck Cancer Related to Co-Factors?

Background and Objectives: Determine the contribution of coexisting factors to the risk to develop Osteoradionecrosis (ORN) of the jaws among patients who have received radiotherapy by intensity modulated radiation therapy (IMRT) for head and neck cancer (HNC) between 2013 and 2016, in a single medical center. Materials and Methods: The records of all patients treated with IMRT for HNC between 2013 and 2016 in The Davidoff Center for the treatment and Research of Cancer in Rabin Medical Center—Beilinson hospital, Petah-Tikva, Israel were screened. Patients who have received a minimum mean dose of 40 Gy to the oral cavity entered the research and their medical records were retrospectively reviewed. Collected background data included: age, gender, smoking, diabetes mellitus (DM), ASA score, mean and maximal radiation doses (Gy), and diseases characteristics including histological diagnosis, primary tumor site, and disease stage. Results: A total of 1232 patients were surveyed. Out of all screened patients, 93 received a minimum mean dose of 40 Gy to the oral cavity. Out of the 93 patients, 7 (7.52%) developed ORN (ORN+) and 86 did not develop ORN (ORN−). Tumor type in all seven patients in the ORN+ group was Squamous Cell Carcinoma (SCC). In three out of those seven patients (42.9%), the tumor was located in the mandible. Conclusions: within the limits of the relatively small cohort in the current study, we suggest that the development of ORN due to Radiation therapy (RT) with IMRT is related significantly only to the location of a tumor in the mandible. Other co-factors do not significantly increase the risk to develop ORN when RT is delivered via IMRT.

Occurrence and Treatment Outcome of Late Complications After Free Fibula Flap Reconstruction for Mandibular Osteoradionecrosis

PURPOSE

This study aimed to evaluate the occurrence and treatment outcome of late complications after free fibula osteocutaneous flap reconstruction for mandibular osteoradionecrosis (ORN).

METHODS

We enrolled 15 consecutive patients (14 men, one woman; median age 65 years, range 57-80 years) who underwent free fibula reconstruction for advanced mandibular ORN during 2013-2017 with two or more years of follow-up. Late complications included infection, plate exposure, and recurrence at the resection margin. The effect of perioperative antibiotic administration on late complications was also assessed.

RESULTS

Late complications occurred in 33.3% (5/15) of patients, including two infections (local and distant), two plate exposures, and two recurrences (plate exposure and recurrence occurred in one patient). Perioperative antibiotic administration duration did not significantly affect the occurrence of postoperative late complications. All late complications were treated without problems.

CONCLUSIONS

Late complications after ORN reconstructive surgery are not uncommon, but can be treated properly.

Clinical utility of hyperbaric oxygen therapy in dentistry

This fuller impact of the use of hyperbaric oxygen therapy within dentistry is taking greater notice with newer research findings. There are new advancements in research regarding postradiotherapy cases, osteonecrosis of the jaw, osteomyelitis, periodontal disease, and dental implants. Hyperbaric oxygen therapy can even be used in conjunction with other procedures such as bone grafting. Although the research and clinical utility has come a long way, there are several complications to be mindful of during the application of hyperbaric oxygen therapy.

Osteoradionecrosis of Jaw: An Institutional Experience

Aims and Objectives:

Osteoradionecrosis (ORN) of the jaw is a significant yet rare complication of radiotherapy (RT) associated with the management of head-and-neck malignancies. Recent decrease in the incidence of ORN following RT to the head and neck is being mainly attributed to refinement in RT techniques and improvement in our understanding of this morbid disease. The aim of this study is to assess the patients with ORN following head-and-neck RT to determine the various contributing risk factors involved in the development of ORN.

Subjects and Methods:

A retrospective data review from 2003 onward was conducted on the cases of ORN which presented to the Department of Dental and Oral Surgery, Christian Medical College, Vellore. Details of the patients with regard to the site of primary malignancy, type of treatment provided - RT alone or in combination of surgery and chemotherapy, dose of RT, presenting complaint, duration between the RT and presentation of ORN, and method of management considered were evaluated.

Results:

A total of 25 patients were evaluated. The average age of the 25 patients in our study was 58 years. Oropharynx (about 50%) was the leading site of primary malignancy. More than half of the patients in the study (52%) had undergone radical RT for the primary malignancy and all the patients were given >60 Gy dose of RT. About 48% of the patients in the study reported with pus discharge as their chief complaint. The average intervening time period from completion of RT to the presentation of ORN was 48 months. The mandibular alveolus was the most common site for ORN. Twelve of the 25 cases in the study were managed conservatively with only 3 patients requiring major resection.

Conclusion:

Due to its rare presentation, ORN still remains a challenge for the clinician in its management. Our study revealed that radical RT and concurrent chemo-RT for the oropharyngeal and base of the tongue malignancies have a higher risk of developing ORN. Patients subjected to the dose of RT above 60 Gy for head-and-neck malignancies have an increased risk of future ORN; henceforth, newer modality treatment like intensity-modulated RT regimen is recommended for such sites. Most of the patients in the study were satisfactorily managed of the symptoms with conservative modality treatment; hence, it is recommended to consider for surgical methods only in severe end-stage form of ORN.

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.