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Osteoradionecrosis of the Jaw

Definition

Osteoradionecrosis is a condition characterized by non-viable, non-healing and aseptic lesions in bones undergoing radiation exposure. It generally affects the jaw bones after radiation therapy for treating cancers in the head and neck region. Radiation therapy not only destroys the tumor cells but also leads to damage to the normal architecture of the surrounding tissues. A key factor in osteoradionecrosis development is traumatic events such as tooth extraction.

Symptoms

Osteoradionecrosis is seen in patients with a history of radiation therapy or radiation exposure. The condition is painful, debilitating and usually difficult to treat. It presents with severe, deep, bony pain in the affected region of jaws for weeks to months. If any secondary infection develops at the site (osteomyelitis of the jaw), swelling and edema may also be present. Frequently soft tissue abscess and chronic pus drainage is seen and it tends to have a fetid odor.

As the disease progresses in the jaw bones, normal functioning of the mandible can be affected. Opening of the mouth may become limited and the difficulty in moving the jaw may also be experienced. In severe cases the bone may become exposed to the external environment. Within the mouth, the offending tooth or a traumatic lesion may be present.

Picture from Wikimedia Commons

Causes

Osteoradionecrosis of the jaws mostly occurs spontaneously after a traumatic event in patients undergoing radiation therapy. It is possible for other reasons for radiation exposure, not related to cancer treatment. The radiation is the predisposing factor. The most common causes of trauma include dental extractions. Lesions over oral mucosa (inner lining of the mouth), dental abscess and surgical excisions can also be few of the factors triggering osteoradionecrosis.

Radiation therapy in patients with tumors in head and neck region leads to destruction of tumor cells. However, the radiations also have side effects resulting in damaging the healthy normal cells in the irradiated body parts. It not only leads to cell destruction but also affects the blood vessels. The damage to the blood vessels leads to reduced oxygen supply in the affected area. The combined effect of a lack of oxygen and cell damage leads to death of the bone tissue leading to osteoradionecrosis.

The effect of radiations on jaw bone depends on following factors :

  • Quality and quantity of radiation.
  • Location and extent of the lesion.
  • Size of the portal used.
  • Dental health of the patient.

Treatment

Treatment of osteoradionecrosis can be conservative or radical depending on the extent of lesion, age and health of the patient. Before beginning of the radiation therapy all required dental treatments should be completed and dental hygiene should be maintained strictly throughout to avoid osteoradionecrosis. Sodium fluoride gels and chlorhexidine mouthwashes are recommdnded.

The conservative treatment of osteoradionecrosis includes the use of systemic antibiotics, analgesics and  debridement of the lesion with antiseptic application The dead bone pieces and sequestra formed in the affected parts of the bone should be removed in a hospital set up.
Radical treatment approaches include intraoral sequestrectomy and bone resection followed by reconstruction surgeries.

Hyperbaric oxygen therapy is a useful adjunct in treating osteoradionecrosis. Use of 100% oxygen improves the oxygen supply to the affected bone with damage to the blood vessels. It is also necessary for sustaining bone graft healing.

References :

http://emedicine.medscape.com/article/851539-overview

http://www.oralcancerfoundation.org/treatment/osteoradionecrosis.html


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