FIGURE 4. Harvested free fibula flap: the large skin paddle will be used to reconstruct the missing soft tissue intraorally, and help close the neck incision and bone to reconstruct the mandible. radiation. If the wound is left open, the patient should be counseled in proper oral hygiene and counseled to have patience. With time, a sequestrum will form and can be easily removed, leaving healthy gran- ulation tissue beneath. Unfortunately, some patients will progress to Stage III ORN. For these individuals, complete resolution of pain, infection and exposed bone can only be accomplished by using free vascularized tissue to rebuild and replace the damaged jaw and missing soft tissue (Figure 4 and Figure 5). These are lengthy surgeries, followed by long hospital stays and prolonged rehabilitation — with the majority of these patients requiring gastric feeding tubes. FIGURE 5. Panorex radiograph showing the reconstructed mandibular defect, with the free fibula flap on the left. Dental providers should understand it is possible to successfully extract teeth and place dental implants in patients who have previously received radiation therapy. However, the risks and benefits of these pro- cedures need to be thoroughly discussed — and informed consent obtained — before providing therapy. This is important because the sequelae to tooth extraction or implant placement often brings nega- tive results. As Cannady et al14 note, “The psychological impact of sur- viving cancer, only to be handicapped by the treatment sequelae, can be crippling.” outcome data) evidence.10 that HBO is effective in the treatment and prevention of ORN.11 There is no clear evidence in the literature A Cochrane review of patients receiving dental implants concluded there is no evidence for or against the effectiveness of HBO in improving dental implant outcomes in radiated patients.12 TREATMENT STRATEGIES Various studies have reported 10% to 100% resolution of symptoms after simple, conservative therapy. When treating patients who are suspected of having ORN, the possibility of recurrent disease must always be ruled out. These are cancer patients and, despite being treated, there is a pos- sibility of recurrence. Verification can be done with a biopsy of the affected site. Once recurrence has been ruled out, treatment can proceed. There are no universally accepted guidelines for the treatment of ORN today, and protocols for HBO that were once accepted as the standard of care in managing ORN are no longer recommended. Proponents of the fibroatrophic theory use two oral medications to help manage ORN. A patient can take 800 mg of pentoxifylline and 1000 IU vitamin E at least two weeks prior to a procedure, and com- plete a two-month course of this regimen. In a study by Delanian et al,13 As oral health professionals, treating patients who have had radia- tion therapy can prove challenging. These patients have survived a momentous hurdle in their lives, and fear of cancer recurrence always lurks in the back of their minds. The controversies surrounding the gen- esis of ORN pose a dilemma when caring for this patient population. When formulating a treatment plan, clinicians must look to the evi- dence and outcomes in the literature — and counsel patients that ther- apy is not a sprint but, rather, a marathon. D REFERENCES 1. Thorn JJ, Hansen HS, Specht L, Bastholt L. Osteoradionecrosis of the jaws: clinical characteristics and relation to the field of irradiation. J Oral Maxillofac Surg. 2000;58:1088–1093. 2. Morrish RB Jr, Chan E, Silverman S Jr, Meyer J, Fu KK, Greenspan D. Osteonecrosis in patients irradiated for head and neck carcinoma. Cancer. 1981;47:1980–1983. 3. Notani K, Yamazaki Y, Kitada H, et al. Management of mandibular osteoradionecrosis corresponding to the severity of osteoradionecrosis and the method of radiotherapy. Head Neck. 2003;25:181–186. 4. Scarborough WL. Osteoradionecrosis in intra-oral cancer. Am J Roentgenol Radiat Ther. 1938;40:524–534. 5. Gowgiel JM. Experimental radio-osteonecrosis of the jaws. J Dent Res. 1960;39:176–197. 6. Meyer I. Infectious diseases of the jaws. J Oral Surg. 1970;28:17–26. 7. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41:283–288. 8. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg. 2008;46:653–660. this therapy reportedly helped. Vitamin E (alpha-tocopherol) is an antioxidant that scavenges free radicals generated during oxidative stress. Pentoxifiylline has been used for the management of vascular disorders, such as intermittent claudication, and has anti-inflammatory mediators, such as TNF-α. In addition to these medications, for early stage ORN, the dentist could consider surgical debridement; and passive closure following the surgical procedure is obligatory. The patient may require oral antibiotics whenever there is an overlying infection. At times, it is difficult to obtain primary closure, and wound dehiscence is common because the soft tissue is contracted from the frequent infections and fibrotic from the DecisionsInDentistry.com 9. Annane D, Depondt J, Aubert P, et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group. J Clin Oncol. 2004;22:4893–4900. 10. D'Souza J, Goru J, Goru S, Brown J, Vaughan ED, Rogers SN. The influence of hyperbaric oxygen on the outcome of patients treated for osteoradionecrosis: 8 year study. Int J Oral Maxillofac Surg. 2007;36:783–787. 11. Lubek JE, Hancock MK, Strome SE. What is the value of hyperbaric oxygen therapy in management of osteoradionecrosis of the head and neck? Laryngoscope. 2013;123:555–556. 12. Esposito M, Grusovin MG, Patel S, Worthington HV, Coulthard P. Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants. Cochrane Database Syst Rev. 2008;23:CD003603. 13. Delanian S, Depondt J, Lefaix JL. Major healing of refractory mandible osteoradionecrosis after treatment combining pentoxifylline and tocopherol: a phase II trial. Head Neck. 2005;27:114–123. 14. 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