International Journal of Oral and Maxillofacial Surgery
International NewsConsensus ReportChinese expert group consensus on diagnosis and clinical management of osteoradionecrosis of the mandible
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.
References (65)
- et al.
Intensity-modulated proton therapy and osteoradionecrosis in oropharyngeal cancer
Radiother Oncol
(2017) - et al.
Lack of osteoradionecrosis of the mandible after intensity-modulated radiotherapy for head and neck cancer: likely contributions of both dental care and improved dose distributions
Int J Radiat Oncol Biol Phys
(2007) - et al.
Symptom burden and dysphagia associated with osteoradionecrosis in long-term oropharynx cancer survivors: a cohort analysis
Oral Oncol
(2017) - et al.
Osteoradionecrosis
Oral Maxillofac Surg Clin North Am
(2011) - et al.
Outcomes of microvascular free flap reconstruction for mandibular osteoradionecrosis. A systematic review
J Craniomaxillofac Surg
(2015) - et al.
Osteoradionecrosis of the jaws current understanding of its pathophysiology and treatment
Br J Oral Maxillofac Surg
(2008) - et al.
Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review
Int Dent J
(2018) - et al.
Refining the definition of mandibular osteoradionecrosis in clinical trials: the cancer research UK HOPON trial (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis)
Oral Oncol
(2017) - et al.
Osteoradionecrosis of the mandible: through a radiologist’s eyes
Clin Radiol
(2015) - et al.
Osteoradionecrosis: an update
Oral Oncol
(2010)
Osteoradionecrosis of the jaws: a review and update in etiology and treatment
Braz J Otorhinolaryngol
Risk factor assessment for the development of osteoradionecrosis
J Oral Maxillofac Surg
Risk of osteoradionecrosis in head and neck cancers Comparison between oral and non-oral cancers
Oral Oncol
Radiographic osteoradionecrosis of the jaw with intact mucosa Proposal of clinical guidelines for early identification of this condition
Oral Oncol
Suppurative osteomyelitis, bisphosphonate induced osteonecrosis, osteoradionecrosis: a blinded histopathologic comparison and its implications for the mechanism of each disease
Int J Oral Maxillofac Surg
Imaging of radiation- and medication-related osteonecrosis
Radiol Clin North Am
Current concepts in osteoradionecrosis after head and neck radiotherapy
Clin Oncol (R Coll Radiol)
Osteoradionecrosis—a review of current concepts in defining the extent of the disease and a new classification proposal
Br J Oral Maxillofac Surg
Retrospective analysis of osteoradionecrosis of the mandible: proposing a novel clinical classification and staging system
Int J Oral Maxillofac Surg
Osteoradionecrosis of the mandible: treatment outcomes and factors influencing the progress of osteoradionecrosis
J Oral Maxillofac Surg
Medical treatment of osteoradionecrosis of the mandible by PENTOCLO: preliminary results
Eur Ann Otorhinolaryngol Head Neck Dis
The influence of hyperbaric oxygen on the outcome of patients treated for osteoradionecrosis 8 year study
Int J Oral Maxillofac Surg
Relationship between oral health status and development of osteoradionecrosis of the mandible a retrospective longitudinal study
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
Osteoradionecrosis and medication-related osteonecrosis of the jaw: similarities and differences
Int J Oral Maxillofac Surg
Pentoxifylline—a review of its use in osteoradionecrosis
Br J Oral Maxillofac Surg
Pharmacologic modalities in the treatment of osteoradionecrosis of the jaw
Oral Maxillofac Surg Clin North Am
Complete restoration of refractory mandibular osteoradionecrosis by prolonged treatment with a pentoxifylline-tocopherol-clodronate combination (PENTOCLO): a phase II trial
Int J Radiat Oncol Biol Phys
Use of pentoxifylline and tocopherol in the management of osteoradionecrosis
Br J Oral Maxillofac Surg
Prevention of osteoradionecrosis of the jaws by low-intensity ultrasound in the dog model
Int J Oral Maxillofac Surg
Effect of bone marrow-derived stem cells and bone morphogenetic protein-2 on treatment of osteoradionecrosis in a rat model
J Craniomaxillofac Surg
Bone margin analysis for osteonecrosis and osteomyelitis of the jaws
Oral Maxillofac Surg Clin North Am
Fibula free flap in the treatment of mandibular osteoradionecrosis
Eur Ann Otorhinolaryngol Head Neck Dis
Cited by (22)
MRONJ and ORNJ: When a single letter leads to substantial differences
2020, Oral OncologyThe role of hyperbaric oxygen in osteoradionecrosis—a prophylactic insight
2023, Australian Dental JournalApplication of indocyanine green in near⁃infrared fluorescence imaging to detect necrotic bone associated with osteoradionecrosis of the jaws
2023, Journal of Prevention and Treatment for Stomatological DiseasesImmune microenvironment: novel perspectives on bone regeneration disorder in osteoradionecrosis of the jaws
2023, Cell and Tissue ResearchOral Management of Patients Undergoing Head and Neck Cancer Treatment
2023, Journal of Maxillofacial and Oral Surgery
- a
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.