OSTEORADIONECROSIS &BRONJ-1 assignment.pptx

a project om osteoradionecrosis

1. OSTEORADIONECROSIS & BRONJ Dept. of Oral and Maxillofacial Surgery PRANAY CHANDRA Final year Roll no: 07 University Roll No:

2. INDEX INRODUCITION PREIDISPOSING FACTORS PATHOGENESIS CLINICAL PRESENTATION TREAMENT BRONJ PREVENTIVE MODALITIES OF BRONJ CONCLUSION

3. Treatment of malignancies with ionizing radiation has saved countless lives in the past 50 years. However, a small percentage of patients treated with radiation for head and neck cancers will develop osteoradionecrosis of the jaw. Patients treated with more than 6000 centigrays of radiation have an approximately 9% incidence of developing mandibular osteoradionecrosis. A newer radiation technique called intensity-modulated radiation therapy (IMRT) has been reported to have a lower incidence of mandibular osteoradionecrosis. Some of these patients will develop exposed intraoral mandibular bone. Many of these patients will go on to heal spontaneously and without complications, but some will develop osteomyelitis and even fractures of the mandible leading to eventual soft tissue necrosis. INTRODUCTION MRI showing osteoradionecrosis in the cervical vertebrae following radiotherapy for laryngeal cancer

4. PREDISPOSING FACTORS Radiation : Doses of < 67.5 Gy delivered in < 6.5 weeks resulted in no cases of ORN as compared to a 50% incidence with higher doses delivered in < 6.5 weeks Trauma and : Surgery When trauma is associated, it is usually caused by tooth removal. Role of trauma is part of comprehensive pathologic process, involving cellular death and collagen lysis , which places a greater energy, oxygen and other metabolic demands on tissues unable to meet them.

5. Habits and Drugs : One of the most prevalent negative factors associated with the ORN patients is the continued heavy use of alcohol and tobacco by 86% of them. These strong tissue irritants significantly contributes to the breakdown of mucosa and exposure of bone Steroids and : Anticoagulants Steroid use before or after radiation therapy reduced the risk of ORN by 96%, by preventing progression to thrombosis, atrophy and necrosis, credited to the protective effect related to inhibition to the initial inflammatory phase of ORN

6. Pathogenesis Marx’s theory : 3 ‘H’ concept— hypocellularity , hypoxia and hypovascularity Marx proposed three types of osteoradionecrosis : Type I ORN that is seen soon after radiotherapy due to devascularisation resulting from combined side effect of surgery and radiation. Type II ORN that occurs many years after radiotherapy following a known traumatic episode. These results from vascular endarteritis of nutrient vessels of the jaw bone combined with poor wound healing of surrounding soft tissues. Type III ORN occurring between 6 months and 3 years post radiotherapy with no specific preceding traumatic episode.

7. CLINICAL PRESENTATION Osteoradionecrosis clinically includes pain, swelling, nonresolving painful mucosal ulcer with evidence of exposed bone or sequestrum . It also leads to : Trismus Malocclusion Telangiectasia formation. Exposed bone in the form of oraL cutaneous fistula formation, Pathologic fracture

8. OPG showing Mandibular osteoradionecrosis with fracture 

9. Treatment The treatment of osteoradionecrosis of the mandible is aimed at: 1. Removal of the necrotic bone. 2. Enhancement of vascularity of the remaining radiation damaged tissues . Management: Initial treatment—control of infection if present. Gentle irrigation of the soft tissue margins—removes debris and reduces inflammation. Supportive treatment with fluids and a liquid or semi liquid diet high in proteins and vitamins. Pain may be controlled with • Narcotic analgesics • Bupivacaine • Alcohol nerve blocks • Nerve avulsion • Rhizotomy Hyperbaric oxygen therapy Pentoxifylline Clodronate Antioxidant (Vitamin E)

10. Marx protocol • Stage I—A total of 30 hyperbaric oxygen exposures at 2.4 atmospheres absolute pressure (ATA) for 90 min in a multiplace chamber or 2.0 ATA for 120 min in a monoplace chamber is needed. • Stage II—Undergo a transoral debridement/ sequestrectomy which attempts at primary mucosal closure. With postoperative healing, an additional 10 sessions of hyperbaric oxygen exposure is given. • Stage III—Undergo mandibular resection of the necrotic segment until the bone margins yield viable bone, i.e. till bleeding is encountered. In those with orocutaneous fistula, the involved skin and fistulous tract are excised followed by closure. • Stage III R: Marx proposes that the reconstructive surgery should be done 10 weeks after resection thus enabling the graft to be placed, into a sufficiently vascular and cellular bed with intact mucosa. Before reconstruction, an additional 20 dives were planned with 10 dives postoperatively.

11. Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ) Bisphosphonate related osteonecrosis of the jaw (BRONJ) is a condition where necrosis of the jaw bone occurs subsequent to dental infection or therapy in a patient being treated with bisphosphonates The three diagnostic criteria of BRONJ are: 1. Currently on bisphosphonate therapy or a history of bisphosphonate therapy. 2. Exposed, necrotic jaw bone nonhealing for more than 8 weeks. 3. No history of radiation therapy to the head and neck.

12. Stages of BRONJ Stage 1 Exposed bone with absence of pain and infection. Stage 2 Pain may be associated with suppuration or infection and intraoral sinus track formation. Stage 3 Extraoral fistula, exposed necrotic bone extending beyond the region of the alveolar bone, pathological fracture, osteolysis extending to the inferior border or oroantral communication.

13. Prevention modalities of BRONJ A detailed full mouth examination should be done prior to treating the patient with an IV bisphosphonates . Extraction of teeth, restoration of optimal periodontal health and needed invasive procedures should be performed before starting the therapy. The studies conducted by two task force members of the AAOMS withapproximately 50 patients concluded that the risk of developing BRONJ associated with oral bisphosphonates increases only when the duration of therapy exceeds 3 years. However, comorbidities , such as chronic cortico -steroid use increase the risk. Dental surgery can be done in these patients after cessation of oral bisphosphonates 3 months before and 3 months after the dental surgery, provided the systemic conditions are stable.

14. CONCLUSION Head and neck cancer patients continue to pose a challenge for surgeons and oncologists. Prevention of ORN by regular follow-up and early diagnosis should be the goal of every health care professional managing patients with head and neck cancer. Improved radiotherapy protocols, multidisciplinary preventive care and reconstructive surgery can help to improve the quality of life of patients suffering from ORN. Recent advances like free tissue surgical transfer, should be considered as treatment of choice for long established cases of ORN, particularly with pathological fracture.