Necrosis

Section 69 - Hyperbaric Oxygen

Handout

Abstracts

001. Fleming, T.J. Oral tissue changes of radiation-oncology and their management. DCNA 34(2):223-237,1990.

002. Foster, J.H. Hyperbaric Oxygen Therapy: contraindications and complications. J Oral Maxillofac Surg 50:1081-86,1992.

003. Hudson, J.W. Osteomyelitis of the jaws: a 50 year perspective. J Oral Maxillofac Surg 51:1294-1301,1993.

004. Van Merkesteyn, J.P. et al. Hyperbaric oxygen treatment of Osteoradionecrosis of the mandible. Experience in 29 patients. Oral Surg Oral Med Oral Pathol Radiol Endod 80:12-16,1995.

005. Sawai, T. et al. Histologic study of the effect of hyperbaric oxygen therapy on autogenous free bone grafts. J Oral Maxillofac Surg 54:975-81,1996.

006. McDonald, K.R. et al. Effect of hperbaric oxygenation on existing oral mucosal carcinoma. Laryngoscope 106:957-9,1996.

007. Woods, G.A., Liggins, S.J. Does hyperbaric oxygen have a role in the management of osteoradionecrosis? Br J Oral Maxillofac Surg 34:424-27,1996.

008. Clayman, L. Clinical controversies in oral and maxillofacial surgery: Part II. Management of dental extractions in irradiated jaws: a protocol without hyperbaric oxygen therapy. J Oral Maxillofac Surg 55:275-81,1997.

009. Tompach, P.C. et al. Cell response to hyperbaric oxygen treatment. Int J Oral Maxillofac Surg 26:82-86,1997.

010.Larsen, P.E. Placement of dental implants in the irradiated mandible: a protocol involving adjunctive hyperbaric oxygen. J Oral Maxillofac Surg 55:967-71,1997.

011.Schwartz, H.C. Is the use of hyperbaric oxygen necessary? J Oral Maxillofac Surg 56:281,1998.

012.Thorn, J.J. et al. The effect of hyperbaric oxygen on irradiated oral tissues: transmucosal oxygen tension measurements. J Oral Maxillofac Surg 55:1103-07,1997.

013.Jisander, S. et al. Dental implant survival in the irradiated jaw: a preliminary report. 12:643-48,1997.

Section 69: Hyperbaric Oxygen
(Handout)

　Handout not available at this time.......　

- Abstracts –

69-001. Fleming, T.J. Oral tissue changes of radiation-oncology and their management. DCNA 34(2):223-237,1990.

Abstract not available at this time......

69-002. Foster, JH. Hyperbaric Oxygen Therapy: Contraindications and Complications. J Oral Maxillofac Surg 50:1081-1086, 1992.

Purpose: Oral and maxillofacial surgery literature is lacking in information regarding patient selection criteria and possible contraindications to HBO therapy, as well as possible risks and/or complications of such therapy. This article details patient selection criteria, discusses relative and absolute contraindications to HBO therapy, and describes the potential risks and complications of this therapy.
Materials: Literature review.
Results: HBO is the intermittent, systemic administration of 100% oxygen under pressure greater than one atmosphere. This therapy produces improved tissue oxygenation due to increased arterial oxygen tension and increased dissolved plasma oxygen content. It also provides a vasoconstrictive response of arteries that is related to the degree of hyperbaric pressure.
　　　　 The only absolute contraindications to HBO is an untreated pneumothorax. Hx of severe asthma, emphysema, or any of the other chronic obstructive pulmonary diseases are at risk. Other contraindications are:

Optic neuritis

Acute viral infection

Congenital spherocytosis

Uncontrolled, acute seizures disorders

Uncontrolled high fever

Upper respiratory tract infections

Pregnancy (questionable)

Psychiatric problems

History of prior thoracic or ear surgery, which would make it impossible to equalize middle ear pressure or pulmonary pressure

Potential Complications from HBO therapy generally involve cavity trauma due to unequal changes in pressure within the cavity and the tissues as a whole as follows:

Eustachian tube dysfunction

Tympanic membrane rupture

Oxygen toxicity

Ear, sinus, or tooth pain

Decompression sickness

Pneumothorax

Arterial gas embolism

Nitrogen emboli to the central nervous system, lung, or joints

Middle ear hemorrhage

Deafness

Changes in vision

Certain types of hemolytic anemia

Fire hazard

Nausea, fatigue, claustrophobia

Equipment malfunction

Summary: Although the potential for problems and complications exist with HBO therapy, these complications rarely occur. A complete medical history and physical evaluation of the patient, and an understanding of potential problems, can usually circumvent the occurrence of complications.

69-003. Hudson, J. W.: Osteomyelitis of the Jaws: a 50-year Perspective. J Oral Maxillofac Surg 51:1294-1301, 1993.

　　　　 A marked decrease in the incidence of osteomyelitis in the bimaxillary skeleton has been recognized and associated with the availability of bactericidal antimicrobial therapy-specifically penicillin. Waldron in a 1943 article mentions penicillin and theorizes on its clinical application in medicine and specifically in dentistry. The etiology of osteomyelitis has been associated with the skin surface bacteria Staphyloccus aureus. Cierny developed an alternative classification for osteomyelitis as acute and chronic forms (table 3). The arbitrary time limit of 1 month is used to identify acute from chronic osteomyelitis. Acute osteomyelitis may manifest itself with fever, malaise, cellulitis, trismus and increase of leukocytosis. Computerized tomography and radioisotope have both been utilized as evaluative aids. Precise identification of the pathogens and tx is most effective and some of the newer ab’s providing affective coverage for more refractory organisms include metronidazole, clindamycin, ticarcillin, and clavulanic acid, a variety of cephalosporins in combination with other ab’s and fluoroquinolones such as ciprofloxacin.
　　　　 Over the last several decades hyperbaric O2 tx has become a potent alternative to surgical reperfusion and enhances host immune response. There are five aspects to hyperbaric O2 tx:

It enhances the lysosomal degradation potential by enhancing the development of intracellular halides in polymorphonuclear leukocytes and O2 radicals that are a major component of the catabolic enzymes of the macrophage lysosome. Formation of these enzymes is depressed or deceased in hypoxic environments found in osteomyelitic foci.

Free radicals of O2 are formed during hyperbaric O2 tx that are toxic to many pathogenic anaerobes that do not have protective intracellular superoxide scavaging enzymes.

Many exotoxins liberated by the pathophysiologic activity of microorganisms are rendered inert by exposures to elevated partial pressures of O2.

Tissue hypoxia is intermittently reversed by the hyperbaric O2 tx, mimicking the tissue level during wound healing by saturating the interstitial plasma above the normal level produced by the hemoglobin O2 transport mechanism.

Lastly, the most important aspect of hyperbaric O2 tx is its positive enhancement of neoangiogenesis in the aerobic portion of the proliferative phase of wound healing.

　　　　 Under the influence of hyperbaric O2 tx, endothelial proliferation is seen in areas of poor microvascular penetration, which in turn allows for reestablishment of the host immune communication and for penetrance into the infection foci, especially in areas surgically disrupted. The usual tx regiment during wound healing cycle is driven into an aerobic metabolic state by exposing the patient to 2.0 ATA (atm’s absolute) for 90 min while breathing 100% O2 x2daily.

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.

69-005. Sawai T, et al. Histologic Study of the Effect of Hyperbaric Oxygen Therapy on Autogenous Free Bone Grafts. J Oral Maxillofacial Surg 54: 975-81, 1996.

Purpose: To clarify the effects of HBO treatment on autogenous free bone grafts, the interface between the grafted iliac corticocancellous bone and the mandible, was histologically examined in rabbits with or without HBO.
Materials & Methods: Sixteen white rabbits had corticocancellous bone harvested from the iliac crest, which was grafted on their mandibles. Eight rabbits served as controls and the other eight, had a total of 30 HBO sessions (20 before and 10 after surgery) throughout the course of treatment. These HBO sessions consisted of (60 minutes at 2.4 ATA 100% inspired flow of oxygen [FiO2] twice a day.
　　　　 The graft and surrounding bone were sampled at 1, 2, 4, or 8 weeks after transplantation, and the effects of HBO were evaluated by light micrography and contact micrography.
Results:After 1 week the experimental group showed marked osteoid and capillary formation at the junction between the host and grafted bone, this was much greater than the control group. At 2 weeks, new bone formation was present in the experimental group, this did not appear in the control group until 4 weeks. The experimental group had shown increased bone remodeling from 4 to 8 weeks, and the margin between the graft and the host bery difficult to differentiate, this was in contrast to the control group when the junction was still identifiable.
Conclusions: In this study, the HBO experimental group showed an acceleration of union between the autogenous free bone graft to the recipient site, when compared to the control group.HBO is especially effective when the recipient site is hypoxic (ie, irradiated site) this is because HBO promotes angiognensis in a hypoxic area.

69-006. McDonald, MD. Effect of Hyperbaric Oxygenation on Existing Oral Mucosal Carcinoma. Laryngoscope 106:Aug 1996, pp: 957-959.

Introduction: HBO therapy is used in head and neck cancer patients for the treatmentof persistent infection or osteoradionecrosis or as an adjunct to reconstructive procedures.
There was concern that recurrences might represent an effect of HBO in facilitating growth of existing clinically occult disease.
　　 Previous research on the effect of HBO on tumor growth has yielded conflicting results. In some series and studies, HBO has seemed to promote tumor growth, while other reports show no initiating or promoting effect. The same dichotomy exists for evidence on the effect of HBO on distant metastasis rate.
　　　　 In a prior study , HBO was administered during the induction of chemical carcinogenesis. Animals receiving HBO had fewer but larger tumors, suggesting that HBO discouraged carcinogenesis but enhanced the growth rate of an established tumor.
　　　　 The current study was designed to investigate the effect of HBO on an established tumor.

Materials and Methods: Oral squamous cell carcinoma was produced using an established model for chemical carcinogenesis. Animals had macroscopic tumors in the buccal pouches.

Group 1 underwent no HBO therapy while group 2 underwent twice daily HBO treatment to 2.81 atm for 60 minutes, for a total of 30 dives. This is a typical course of treatment for osteoradionecrosis.

Results:

Neck metastasis developed in 5% of the HBO group and 22% of the non-HBO group. This was not statistically significant but appeared to trend toward fewer neck metastasis in HBO-treated animals.

Tumor mass of non-HBO animals averaged 1.89g and was significantly greater.

Tumor mass of HBO-animals averaged 0.86g.

Discussion: This study demonstrated an apparent tumorcidal effect of the HBO.

HBO-treated animals had decreased tumor growth by more than 50%

There was an trend toward fewer nodal metastasis in the HBO-treated animals but no difference between groups in the rate of distant metastasis.

The tumorcidal effect seen in these established oral squamous cell carcinomas may result from an HBO-induced increase in free-oxygen radicals. HBO therapy increases tissue oxygen tension (from ambient ppO2 to >2000 mm Hg), which in turn results in formation of peroxide , superoxide, and hydroxyl radicals. These free radicals destroy cell membranes, causing cell death. Thus, the HBO treatments may cause a local chemotherapeutic effect.

Reported clinical recurrence rate of oral squamous cell carcinoma ranges from % for stage 1 lesions to 57.8% for stage 4 lesions.

If patients receive HBO treatment sometime after initial tumor treatment, the recurrence rate drops to 10.5% for stage 1 and 36.3% for stage 4. This finding suggests that HBO treatment may offer protection against clinical tumor recurrence.

These data contradict the reports of patients with precipitous tumor growth during HBO therapy of apparently cured carcinoma.

One explanation for this apparent contradiction may be that the biologic behavior of these rapidly chemically induced carcinomas differs from the biologic behavior of human upper aerodigestive carcinomas, which are usually induced after years of exposure to tobacco and alcohol. A second difference between the animal and human tumors is that all patients with rapid tumor growth after HBO treatment had previously received postoperative radiation therapy, which changed the tumor environment. Radiation therapy induces a relative tissue hypoxia from obliterative endarteritis. HBO raises the radiated hypoxic tissue ppO2 levels to 20-30 mm Hg, while normal tissue ppO2 levels are raised to a greater than 2000 mm Hg. Increasing oxygen tension to a physiologic level in a once-hypoxic tumor may promote tumor growth, while not reaching the oxygen tension levels required to generate the free radicals that might discourage tumor growth.

A review of published information fails to support a cancer-causing or growth-enhancing effect by HBO.

69-007. Wood, GA and Liggins, SJ. Does hyperbaric oxygen have a role in the management of osteoradionecrosis? Br J Oral Maxillofac Surg 34:424-427,1996.

Purpose: To determine the outcome of treatment with HBO in cases of ORN affecting the mandible.
Materials and Methods: A retrospective study of 8 years was carried out. 11 patients were identified with 12 sites of ORN. Previous conservative therapy (antibiotics, oral rinses, debridement, and sequestrectomy )failed. A dive consisted of 100% oxygen at 2 atm for 90 minutes. The protocol was based on that of Marx.
Results: Surgery was required in 83% of the cases but all cases in the study healed.
Conclusion: The HBO therapy was effective in the treatment of ORN.

69-008. Clayman, L. Clinical controversies in oral and maxillofacial surgery: Part II. Management of dental extractions in irradiated jaws: a protocol without hyperbaric oxygen therapy. J Oral Maxillofac Surg 55: 275-81, 1997.

A historical overview of Osteoradionecrosis (ORN) developing following extractions in irradiated bone was given in the introduction. A good argument for HBO therapy before extractions is presented.
Definition of ORN: ORN is a nonhealing, nonseptic lesion of bone in which bone volume and density cannot be maintained by the HYPOCELLULAR, HYPOVASCULAR, HYPOXIC tissue, which canot adequately meet its metabolic demands. This pattern of ORN (Type I) may present with bone lysis under intact gingiva or mucosa. In cases where spsis is directly introduced by the traumaof dental extraction or surgery, an aggresive form of ORN (Type II) may develop, which is better described as osteomyelitis. Type I tends to heal with conservative therapy and Type II does not.
Occurrence: Since 1960’s the occurrence has dropped from 11.8% to 5.4% mostly occuring in the mandible with negligible data in the maxilla.
Radiation Dosimetry: Above 60 Gy but below 70 Gy, ORN occurs more frequently, and above 75 Gy the rate is almost 10 times greater than it is less than 50Gy. The chance of treating ORN above 75 Gy diminishes above.
ORN and tooth removal: Very little difference exists between ORN after both preradiation therapy extractions and postradiation therapy extractions. All authors for 60 years agree that for radiation patients the extraction procedure should be gentle, the vasoconstrictor should be avoided in the local anesthetic, and that the incidence of ORN post extraction remains 5.8 %.
HBO, extractions and ORN: The rates varied greatly for different studies. It seems that HBO helped to improve the symptoms of ORN but in severe cases it did not totally eliminate the symptoms.
Conclusions: The true rate of loss of continuity of mandibles that develop ORN after dental extractions varies greatly between small series, but in aggregate review it is quite low. The postextraction ORN rate was low 2.5%. the author does not suggest mandatory use of HBO before removing teeth in irradiated mandibles.
Comments: After reading this article, I am still waiting to find out what the protocol is and what the author compares it to. Good review of some literature but wrong title for the article!!!!

69-009. Tompach, P. C. et al. Cell Response to Hyperbaric Oxygen Treatment. Int J Oral Maxillofac Surg 26:82-86, 1997.

Purpose: To investigate the effects of hyperbaric oxygen (HBO) on cells involved in wound healing.
Methods and Materials: Cultured endothelial cells and fibroblasts were exposed to HBO. Partial pressure, oxygen saturation, and duration and frequency of exposure to HBO were evaluated.
Results: Increased endothelial cell proliferation occurred after 15 minutes of HBO. Fibroblasts required 2 hours of HBO to produce. A second exposure to HBO on the same day produced no additional cell proliferation. A 2 hour HBO exposure stimulated fibroblast proliferation for up to 72 hours after the exposure. An increase in partial pressure from 2.4 to 4.0 atmospheres did not enhance the proliferative response.
Conclusion: A common problem in non healing wounds is due to inadequate perfusion. The effects of hypoxia leads to decreased fibroblast migration and decreased collagen synthesis. Results of the experiments indicate that endothelial cell and fibroblast growth are augmented by HBO treatment. In vivo, it is difficult to determine the exact oxygen level to which cells involved in the wound healing process are exposed. Further studies are needed to obtain optimal healing using fewer and shorter HBO treatment.

69-010. Larsen, PE Placement of dental implants in the irradiated mandible: a protocol involving adjunctive hyperbaric oxygen. J Oral Maxillofac Surg 55: 967-71, 1997.

Purpose: The article presents a protocol for the rehabilitation of the irradiated patient using an implant-supported prosthesis. An integral component of this protocol is the use of hyperbaric oxygen.
Subject: Doses of irradiation greater than 5000cGy produce a hypoxic hypocellular and hypovascular tissue bed that exhibits poor wound healing.
Methods and materials: Hyperbaric oxygen exerts a beneficial effect on osteogenesis through stimulation of capillary ingrowth, fibroblastic proliferation, collagen synthesis, and capillary angiogenesis. Sustained increase in oxygenation occurs after approximately 8-10 treatments. Wait a minimum of 6 months after irradiation before implant placement. A regimen of 20 preoperative treatments of 100% oxygen at 2.4 atmospheres for 90 minutes, and 10 treatments after surgery. The length of time between implant placement and uncovering is 6 months in the mandible and 9 months in the maxilla. Avoid the potential for trauma from a tissue borne prosthesis by designing an entirely implant supported hybrid type prosthesis. For patients who currently have implants and then require irradiation therapy, it is recommended that these implants be buried before irradiation and 20 HBO treatments be instituted before uncovering after irradiation.
Results: A significantly greater quantity of bone-implant contact resulted around implants placed into irradiated rabbit tibias when treated with hyperbaric oxygen compared with those without HBO. In clinical studies when HBO is used for patients who have implants placed into irradiated bone, there has been a predictably high success rate.
Conclusion: Consistent success is possible for placing implants into irradiated bone when a systematic protocol of hyperbaric oxygen is used.

69-011. Schwartz, H.C. Is the use of hyperbaric oxygen necessary? J Oral Maxillofac Surg 56:281,1998.

Abstract not available at this time.....

69-012. Thorn J.J, Kallehave F, Westergaard P, Hansen E, Gottrup F. The Effect of Hyperbaric O2 on Irradiated Oral Tissues: Transmucosal O2 Tension Measurements. J Oral Maxillofac Surg 55:1103-1107, 1997.

Purpose: To measure the effect of hyperbaric O2 (HBO) tx on transmucosal O2 tension in irradiated human oral mucosa.
Methods: Ten patients received 30 dives of HBO as part of their tx for mandibular osteoradionecrosis. A noninvasive, nonheated O2 electrode was used to measure the tissue surface transmucosal O2 tension directly on the attached gingiva. Measurements were done before, during, and after HBO tx. The normal level of gingival surface transmucosal O2 tension was measured in five healthy volunteers.
Results: During HBO tx, the transmucosal O2 tension increased significantly after five dives of HBO (p, .05). After 30 dives, the increases were from a mean of 50% to a mean of 86% of the transmucosal O2 tension of normal healthy tissue.
Conclusion: An increase in the transmucosal O2 tension is based on the neo-angiogenesis. Patients with subischemic tissues, such as the study population with postirradiation mucosal and osseous necrosis, therefore may benefit from treatment with HBO.

69-013. Jisander, S. et al. Dental implant survival in the irradiated jaw: a preliminary report. 12:643-48,1997.

Abstract not available at this time....

KTeacher said:

Again

Thank you.  Please do not leave this site, I for one appreciate your time and effort to confirm the medical issues that present themselves to us down the road.  I also like to hear about the things that you do on this side of treatment.  I don't know what my facial issues are but wonder if this might be in my near future.

Thank you very much for this information.  I too am looking at some necrosis issues 3.5 years after Rads.  I am having teeth pulled in a few weeks after HBO and was looking for more information/data on the subject....The more you know, the more you know.....

You're the man for posting this info....

Steve

John,

I think Pat about covered it.

Good  luck, I hope that is a bullet I might dodge.

Now to brush my teeth and off to bed.

Matt

fisrpotpe said:

Dodge Bullet

Matt, i sure hope and pray everyone dodges the necrosis bullet. 

If anyone out there has dealt with this gift that keeps on giving, i would like to hear your story. 

john 

He's been through extensive HBO and debridement.  Mike seems to  only post about once a month, but does respond to PM.  Here are some articles that are more to the point of treatment of established ORN.  I hope the links  work.  If not let me know.  I'm having trouble gettingg to the site to post lately.

http://www.ncbi.nlm.nih.gov/pubmed/12525198

-- this shows good results to replacement surgery, suggests HBO may not be necessary

http://www.ncbi.nlm.nih.gov/pubmed/7552851

-- this shows very good results to ORN and debridement

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

-- good comprehensive article

baromedical.com/assets/blog/211-268.pdf   —the definitive mother of all articles on ORN. pdf format so you have to google it