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Chinese expert group consensus on diagnosis and clinical management of osteoradionecrosis of the mandible

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Abstract

Osteoradionecrosis of the mandible (MORN) is one of the most devastating complications caused by radiation therapy in the head and neck region. It is characterized by infection and chronic necrosis of the mandible as the main manifestation. Clinically, MORN-related symptoms include swelling, pain, dysphagia, trismus, masticatory or speech disorders, refractory orocutaneous fistula, bone exposure, and even pathological fracture. MORN has become a challenging clinical problem for oral and maxillofacial surgeons to deal with, but thus far, this problem has not been solved due to the lack of widely accepted treatment algorithms or guidelines.

Because of the nonexistence of standardized treatment criteria, most clinical treatment against MORN nowadays is largely based on controversial empirical understandings, while recommendations on post-therapeutic evaluations are scarce. Therefore, to further unify and standardize the diagnosis and treatment of MORN, to decrease the huge waste of medical resources, and ultimately, to improve the wellbeing of the patients, the Chinese Society of Oral and Maxillofacial Surgery (CSOMS) convened an expert panel specialized in MORN from 16 domestic medical colleges and affiliated hospitals to discuss the spectrum of diagnosis and and formulate treatment. In addition, consensus recommendations were also revised with a comprehensive literature review of the previous treatment experiences and research pearls. This ‘expert consensus statement on diagnosis and clinical management of MORN’ is for clinical reference.

Section snippets

Definition

Regaud was the first to report the osteoradionecrosis of the jaws (ORNJ) about 90 years ago. Since then, numerous definitions have been proposed4. In 1983, Marx defined MORN as ‘an area greater than 1 cm of exposed bone in a field of irradiation that had failed to show any evidence of healing for at least six months’8, 9. Harris reduced the non-healing interval to 3 months and mentioned the absence of recurrent tumour in the same region9. Based on Store’s findings, from a radiological

Etiopathogenesis and risk factors

ORNJ was firstly considered as an infectious disease caused by the invasion of oral microbiological flora into the irradiated bone tissue. In 1970, Meyer proposed the classic triad theory in the pathogenesis of ORNJ as radiation, trauma and infection4. In 1983, this theory was challenged by Marx as hypoxia, hypovascularization and hypocellularity, instead of trauma and infection, were more likely to be involved in the formation of aseptic necrotic bone11. In 2004 and 2011, radiation-induced

Diagnosis and examinations

Currently, the diagnosis of MORN is mainly based on the following aspects: (1) radiation history; (2) bone exposure with or without surrounding mucosal or epidermal damage; (3) radiological evidence of bony destruction; (4) non-existence of tumour recurrence19; (5) pathological findings of necrotic or sclerotic bone with empty osteocyte lacunae, blurry or breakdown of bony trabeculae, with loss of osteocytes and osteoblasts, and reduced vascularity of connective tissue20.

Staging system

In 1983, Marx introduced the first staging system for ORN patients based on the response to hyperbaric oxygen (HBO) therapy26. Over the years, many other staging systems have been proposed to aid treatment, though controversies still exist over the universal acceptance. In 2000, Store defined the four distinct clinical stages based on the exposure of bone and radiological changes6, 11, 27. Epstein proposed the staging on the progress of the disease, in which stage I is resolving while stage III

Treatment

Management of MORN includes conservative (medical) and surgical interventions4, 6, 29. The mainstay treatment of MORN comprises primarily of symptomatic relief and prevention of further disease exacerbation. Without appropriate management, early-stage MORN patients will progress to advanced stage, which often requires serious resection followed by flap reconstruction30. Recent advances in the understanding of MORN pathophysiology have opened new perspectives in the conservative management of

Outcome evaluation

Most MORN patients need close follow-up for recurrence after certain kinds of treatment. The efficacy of the treatment employed should be subjectively and objectively evaluated on four basic dimensions: local pain, trismus, wound healing and radiographic changes. We recommend using the simplified evaluation methods for a rapid overview of the treatment outcomes during the outpatient visit for follow-up (Table 4).

Prevention of MORN

The prevention of MORN lies in the understanding of the specific aetiology of such complications58. There are three key factors in the development of MORN: radiation, patient and tumour4, 59, 60. As for radiation factors, using different mandible-sparing techniques, lowering total radiation doses, changing radiation sources and modifying radiation schemes, the incidence of MORN can be significantly reduced15, 16. The conditions of patients are also implicated in the formation of MORN. Dental

Funding

None.

Competing interests

None.

Ethical approval

The ethical exemption was given by the Institutional Clinical Research Ethical Committee of Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine.

Patient consent

Written patient consent was obtained to publish clinical photographs.

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    These authors contributed equally to this work. C. Ma and J. Hou are the only first authors of the article, while Y. He is the only corresponding author of this article.

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    © 2019 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.