Osteoradionecrosis (ORN) and hyperbaric therapy (HBO)

jeb54321

Hi! My radiation and chemo treatment ended 9/2009 for squamous-cell on the base of my tongue. I've lost 50-90% of my saliva production, and I've never recovered the ability to taste sweetness.

A few months ago I experienced pain in my lower inner gum. Eventually, a piece of bone pushed it's way out through my gum. An oral surgeon has since removed two bone fragments, and although my gum healed over, sensitivity in the area may mean there is more on the way.

The prelude to this was earaches, headaches, diffuse pain, TMJ, etc. A persistent earache was what led to my initial diagnosis, so I was concerned. An MRI confirmed no new cancer. It was complicated by a failed tooth in the same area that needed a root canal at about the same time, but weeks after that, I still have discomfort and a "bump" in my mouth where the bone erupted.

The oral surgeon confirmed the diagnosis of osteoradionecosis of the jaw, but did not recommend anything but debridement as necessary. But my endodontist suggested I mention it to my radiation oncologist (doh! Why didn't *I* think of that) which I did. He and my ENT vigorously proposed hyperbaric oxygen (HBO) therapy, and when I told my oral surgeon, she concurred.

I've since seen a head and neck oncologist who is currently trying to get insurance approval for 30 two hour oxygen treatments as therapy for the ORN.

Whew! It's been and interesting few months.

My question: I've seen hyperbaric oxygen discussed for lots of things, but not as a treatment for simple ORN. I'm curious if anyone else is familiar with HBO as a treatment when surgery or dental work is not actively being considered? Although the treatment is coming AFTER diagnosis, is use of HBO as a prophylactic ever used? For all the miracles it claims to perform, I'd think post-cancer treatment should include a coupon for 30 days HBO automatically.

I'd also like to know more about the prognosis for ORN patients. My H&N guy explained that I can have HBO now, or wait till it gets worse, have my jaw reconstructed, and have HBO *THEN* (I assume that's the case he's presenting to insurance). I'm just concerned how about how serious this is, what alternatives there are (if any), and why, after radiation of my jaw (paired with cautions about dental health) I've never even heard of ORN before now. I assume that somewhere in the mounds of paperwork I signed, it was mentioned, but it certainly was never put on my radar.

I'd appreciate hearing about an personal experiences with this stuff.

Thanks!

Jim

ratface

No direct experience but have researched it

Hi Jim

No I have not experienced it but yes it's used as you propose, read the following excerpt near the end of the article.




69-004. Van Merkesteyn, J.P., et al. Hyperbaric Oxygen Treatment of Osteoradionecrosis of the Mandible. Experience in 29 Patients. Oral Surg Oral Pathol Radiol Endod 80: 12-16, 1995.
Purpose: To validate that treatment with hyperbaric oxygen (HBO) is an effective means of treating Osteoradionecrosis (ORN). ORN for a long time was thought to be osteomyletis in irradiated bone, but research by Marx redefined ORN as a metabolic and tissue homeostatic deficiency created by radiation- induced cellular injury. ORN is characterized by the sequence: radiation, formation of hypoxic, hypovascular, hypocellular tissue, followed by tissue breakdown and resulting in a chronic, nonhealing wound. The obliteration of the inferior alveolar artery is the dominant factor in the onset of ORN. The use of HBO is to revascularize irradiated tissue and improve the fibroblastic cellular density, thus limiting the amount of nonviable tissue to be surgically removed, enhancing wound healing and preparing the tissues for reconstruction.
Methods & Materials: 29 patients (17 male, 12 female) with an ORN of the mandible were used. Most of the patients were treated for squamous cell carcinoma of the floor of the mouth or tongue. HBO treatment consisted of 90 minute sessions in a multiplace chamber at a pressure of 3 atmospheres absolute, breathing 100% by mask . 24 of the 27 patients underwent a regime of 30 preoperative and 10 postoperative sessions. Antibiotic treatment for most of the patients consisted of one million units of penicillin G preoperatively followed by four additional postoperative doses in 24 hours intravenously and one week of feneticillin 625 mg orally four times daily.
Results: After initial treatment, ORN was resolved in 15 patients. Eight patients after receiving additional treatments saw ORN resolved. Six patients developed a small dehiscence or an inactive fistula.
Discussion: Treatment of ORN should be aimed at the removal of nonviable tissue, revascularization of the tissues and preparing the tissues for reconstructive surgery when indicated. A staging protocol for the treatment of ORN in the mandible (developed by Marx) is stage I – 40 sessions of HBO; stage II – surgical debridement combined with 30 preoperative and 10 postoperative sessions of HBO; stage III – 30 preoperative and 10 postoperative HBO sessions given in combination with a continuity resection of the mandible. HBO treatment has been effective in animal studies and human subjects.

ljoy

HBO
I posted this last year but thought it would be helpful to re-post for your information.

Four and a half years after tonsil cancer treatment another phase of the cancer journey has entered my life. While eating a few weeks ago I bit down on a piece of food and felt what I thought was a loose crown.I immediately made a dentist appointment.

A quick exam revealed a loose tooth as opposed to a loose crown. The x-ray showed tissue and bone deterioration around and under the tooth. It is my right lower jaw tooth. It is also the side I received the most radiation (7200 rads). My dentist referred me to an Endodontic specialist for a root canal. Based on the x-ray and oral examination he was not sure the deterioration was caused from a root problem. However, based on my history and wanting to do everything possible to save the tooth he preceded with a root canal. Afterwards he suggested I see a peridondist as well.

I decided to seek a different opinion at this point. I met with the Radiation Oncologist at the cancer center where I volunteer and serve as a mentor for Head and Neck patients. He referred me to an oral surgeon who treats a lot of cancer patients. After further examination he has determined it is radionecrosis (tissue damage from radiation treatment). Even a lay person can see the change in the bone and tissue around the tooth.

I began Hyperbaric Chamber treatmenta last week. I will have thirty treatments and then oral surgery to remove the tooth. Another ten treatments will be necessary after the surgery to help promote healing of the bone and tissue. If they pull the tooth before the hyperbaric treatments they are convinced it will not heal.

The good news is the treatments are painless. However, I have a 75 mile commute one-way to the facility. The treatments are an hour and fifty minutes. The chamber holds 8 - 10 patients per session. I have had a little problem keeping my ears clear from the pressure. It is suppose to get better as I complete more treatments.

Hopefully, the hyperbaric treatments will restore circulation to the damaged area. This will reduce the amount of dead bone to be removed during surgery and help the area to heal properly afterwards.

This has nothing to do with good oral hygiene after treatment. So everybody please continue to be diligent in checking your mouth for any potential problems. I feel my regular dentist could have done a better job. I had a checkup and cleaning in early December and the loose tooth was not detected. Perhaps we all should consider annual x-rays to look for tissue and bone deterioration from radiation.

It is also very interesting that three other patients receiving treatments for the same reason. I will post an update once I finish to let all of you know how successful the treatments were in preventing further problems.

A year later (4-21-2011) I'm totally healed. It definately did work for me.