Graham I Smith - The Royal Marsden

royalmarsden.nhs.uk

Graham I Smith - The Royal Marsden

RMH Head and Neck Study Day 21.01.13Osteo-radionecrosis andDental Issues Post EBRTGraham I Smith FRCS(Eng), FRCS(OMFS)Consultant Oral & Maxillofacial/ Head & Neck SurgeonSt George’s Hospital/Kingston Hospital


The issues•Definition•Epidemiology / Risk factors•Staging / Classification•Pathophysiology•Clinical features•Management


Definition


Definition


EpidemiologyIncreased risk:•Mandible > Maxilla•Mandible 5-15%•Exposure > 60Gy•Brachytherapy•ChemoradiotherapyDecreased risk:•Hyperfractionated radiotherapy


Classification•Clinical and Radiological criteria•Soft tissue and hard tissue features•Based on responsiveness to treatment:MarxNotaniEpstein•LENT and SOMA scales by RTOG


Classification (Marx)


Classification (Notani)Grade 1:•ORN confined to alveolar boneGrade 2:•ORN alveolar bone and/or mandible above the level ofinferior alveolar canalGrade 3:•ORN involving the mandible below the level of inferioralveolar canal / skin fistula /pathologic fracture


Classification (Notani)


Classification (Notani)


Classification (Notani)


Watson & Scarborough (1938)•exposure to RT•injury•infectionMeyer (1970)•Radiation – trauma - infectionMarx (1983)•Hypoxia-hypocellular-hypovascular theory•Complex metabolic & homeostatic deficiency created by IR-induced•Cellular injury – Cornerstone for HBODelanian (2004)•Fibroatrophic theoryPathophysiology


Pathophysiology (Marx)


Delanian


Delanian


Clinical presentation


Clinical presentation


Clinical presentation


Investigations•Radiology- OPG/CT +/-MRI•Biopsy•Microbiology•Haematological


Radiological features


Radiological features


Radiological features


Radiological features


Radiological features


Management•MDT•Prevention•Medical•Surgical


MDT-Adjuvant RadiotherapyShould be based on clinical and pathologicalprognostic factorsAdvanced clinical stageClose or positive marginsMultiple positive nodesExtracapsular spread


PreventionIndications for dental extraction:•Gross caries•Retained roots•Teeth with apical pathology•Teeth associated with tumour•Periodontally involved teeth•Non-functional teeth•Teeth close to osteotomy cuts•Inaccessible teeth (wisdom teeth)


Medical management•Good OH and mouthwashes•Antibiotics (Oxy-tetracycline, Clindamycin)•Nutrition•Pain control•Psychosocial support•Pentoxifylline, Vitamin E• Clodronate•HBO


Medical -PentoxifyllinePentoxifylline is a methylxanthine derivative:•Anti-TNF effect•Increases erythrocyte flexibility•Dilates blood vessels•Inhibits inflammatory reactions in vivo•Inhibits proliferation of human dermal fibroblasts•Inhibits production of extracellular matrix•Increases collagenase activity in vitroDose: 400mg po BD 6-24 months


Medical-Vitamin E (Tocopherol)•Scavenger of reactive oxygen species (ROS)•Protecta cell membranes against peroxidation of lipids•Partial inhibition of TGF-1•Inhibits expression of procollagen genes thus reducing fibrosisDose: 1.000 Units PO OD 6-24 monthsSynergistic effect with Pentoxifylline


Medical-Clodronate•Clodronate is a new generation bisphosphonate•Inhibits bone resorption by reducing number and activityof osteoclasts•Acts directly on osteoblastic cells increasing formation of bone•Reduces proliferation of fibroblastsDose: 1600mg PO OD 6-20 months


Clinical trial-DelanianPhase II clinical trial:•18 patients•Exposed mandible 13.4mm•Daily pentoxifylline 800mg•Vitamin E 1000 IU orally for 6–24 months•8 severe cases Clodronate 1600mg/day 5 days a week•All patients had improved at 6 months•16/ 18 recovered completely, 14 within 8 months.•2 patients did not respond as well


Treatment


Hyperbaric Oxygen (HBO)Hyperbaric oxygen (HBO) is oxygen delivered at greater than1 atmosphere of pressure in a chamber or pressure vesselwith the intent to elevate tissue oxygen partial pressure(PaO2) beyond that attainable by breathing 100% oxygen atsea levelContraindications:•Optic neuritis•Pulmonary disease•Claustrophobia•Seizure disordersComplications:Eustachian tube dysfunctionMiddle ear barotraumasTympanic membrane ruptureGeneral seizuresDecompression sickness


Surgical•Debridement•Sequestrectomy•Resection + reconstruction with vascularised bone


Composite free flapsFibular free flapComposite radial forearmScapularDCIA


ReferencesHyperbaric Oxygen Therapy for Radionecrosis of the Jaw: A Randomised, Placebo- Controlled, Double-Blind TrialFrom the ORN96 Study Group: Annane et al;J Clin Oncol 22: 4893-4900, 2004Marx R. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41:283–288Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg. 1983;41:351–357Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: a randomized prospective clinical trial ofhyperbaric oxygen versus penicillin. J Am Dent Assoc. 1985;111:49–54Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidantpathway. Radiother Oncol. 2004;73:119–131Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment, British Journal of Oraland Maxillofacial Surgery Vol. 46, Issue 8, Pages 653-660Hyperbaric oxygen in the management of late radiation injury to the head and neck. Part I: treatmentBritish Journal ofOral and Maxillofacial Surgery Vol. 49, Issue 1, Pages 2-8Hyperbaric oxygen in the management of late radiation injury to the head and neck. Part II: prevention,British Journalof Oral and Maxillofacial Surgery Vol. 49, Issue 1, Pages 9-13


Thank youLeandros Vassiliou DDS MD MRCSOMFS Specialist Registrar

More magazines by this user
Similar magazines