Application of indocyanine green in near-infrared fluorescence imaging to detect necrotic bone associated with osteoradionecrosis of the jaws / 口腔疾病防治

Objective @# To investigate the application of indocyanine green in near-infrared fluorescence imaging to determine the scope of necrotic bone resection in osteoradionecrosis of the jaw and to provide a reference for clinicians@*Methods @#Eight patients with osteoradionecrosis of the jaws were enrolled. Indocyanine green was intravenously injected through the elbow vein 10 minutes before osteotomy. After conservative resection of necrotic bone lesions based on imaging results, the scope of potential dead bone resection in the area of low fluorescence intensity was gradually expanded at an initial distance of 0.3 cm. Near-infrared fluorescence imaging and fluorescence intensity determination of bone cross-section were performed before and after extended resection. Statistical differences were analyzed. All patients with osteonecrosis underwent regular follow-up to evaluate the postoperative efficacy@*Results@#Indocyanine green was injected into all 8 patients with osteoradionecrosis for near-infrared fluorescence imaging and the scans were clear; the fluorescence intensity of fresh bone wounds with an expanded mandibular resection range of (0.95 ± 0.14) cm was (226.2 ± 15.8) au, which was higher than that based on intraoperative macroscopic observation and radiological results (108.8 ± 3.4) au, (t = 20.718, P<0.001). The postoperative follow-up improvement rate of 8 patients was 87.5%.@* Conclusion @#Near-infrared fluorescence imaging with indocyanine green can assist in the successful removal of necrotic bone until fresh bleeding of the jaw wound occurs, which has important clinical value in defining the resection range of osteoradionecrosis of the jaw.

Effects of systemic Anatolian propolis administration on a rat-irradiated osteoradionecrosis model

Abstract Objective Radiotherapy after head and neck cancer is associated with the risk of osteonecrosis development. This study aims to investigate the effectiveness of systemic propolis application to prevent the disease as it has no definite treatment protocol despite the proposed treatment methods and significantly decreases individuals' quality of life. Methodology In total, 29 male Wistar-Albino rats were divided into control, 35 Gy irradiation (Group 1), 35 Gy irradiation+100 mg/kg/ml propolis administration (Group 2), and 35 Gy irradiation+200 mg/kg/ml propolis administration groups (Group 3). Propolis was first applied on the day after radiotherapy, except for the control group. Right first and second molars were extracted from all rats three weeks following radiotherapy. Samples were collected seven weeks after radiotherapy. Osteoblast and osteoclast counts were calculated by histomorphometric analysis. Immunohistochemical analysis determined bone morphogenic protein-2 (BMP-2) and transforming growth factor beta-3 (TGFβ-3). Results Group comparison found non-significant differences regarding osteoblast (p=0.130) and osteoclast (p=0.063) counts. However, Group 1 showed the lowest mean osteoblast (OBL: 82.63 [±13.10]) and highest mean osteoclast counts (OCL: 12.63 [±5.55]). OBL/OCL ratio showed significant differences between groups (p=0.011). Despite the significant difference between the Control and Groups 1 (p=0.006) and 2 (p=0.029), Group 3 showed a non-significant difference (p=0.091). For BMP-2 and TGFB3, the control group showed significant differences with the other two groups (p<0.001), except for Group 3. Conclusion Anatolian propolis showed beneficial effects in a radiotherapy-mediated osteonecrosis model, highlighting its potential as a promising intervention.

Clinical dental management of the head and neck irradiated patient: topics of interest for clinicians

To discuss important topics regarding the dental procedures performed in patients before, during and after the radiotherapy treatment. The biological effects of ionizing radiation on bone tissue focusing on clinical care will be described. The invasive and not invasive procedures after radiotherapy treatment in the head and neck region will be addressed using scientific evidences to determine the appropriate moment for tooth extractions, periodontal management, and preventive procedures for osteoradionecrosis. Methods: Thirty-three studies including original studies and reviews were selected in MEDLINE database (PubMed). No year of publication restriction was applied. Language was restricted to the English, and the following Medical Subject Heading terms were used: radiotherapy, osteoradionecrosis, dental management. Studies of osteoradionecrosis involving clinical management of irradiated patients, with an emphasis on updated guidelines and protocols were selected. Results: Care in dental procedures were related about restorative treatment, endodontic treatment, rehabilitation for edentulous regions using prostheses and implants and periodontal procedures before, during and after RTX treatment. Conclusions: The dental procedures should and can be performed before, during but also after radiotherapy. However, the clinical procedures should be less invasive as possible. A maintenance plan that reduces the necessity for major and more invasive treatments after radiotherapy is recommended

Pentoxifylline-tocopherol-clodronate combination in the treatment of localized temporal bone osteoradionecrosis / 中华放射医学与防护杂志

Objective:To determine the effects of pentoxifylline-tocopherol-clodronate combination (PENTOCLO) protocol in the treatment of localized temporal bone osteoradionecrosis (TBORN).Methods:A retrospective analysis was conducted on the clinical data of 21 patients, who suffered localized TBORN (23 ears) and were treated with the PENTOCLO protocol in Sun Yat-sen Memorial Hospital, Sun Yat-sen University from November 2020 to April 2021. The curative effects of the PENTOCLO protocol were evaluated based on the changes in ear symptoms and the extent of exposed bone before and after treatment.Results:The PENTOCLO protocol was applied for (506 ± 48) d on average. As a result, 19 ears (82.6%) became free of earache and purulent ear discharge, and two ears (8.7%) showed alleviation of symptoms. Moreover, nine ears (39.1%) exhibited re-epithelialization in the ear canal, 11 ears (47.6%) showed a decrease in exposed ear canal bone, and the osteonecrosis of three ears (13.0%) was stable.Conclusions:PENTOCLO has encouraging treatment effects on TBORN, and thus can be used as an effective nonsurgical option for localized TBORN.

Risk factors for jaw osteoradionecrosis: a case control study

Abstract There are divergences among studies regarding features associated to increased risk of osteoradionecrosis (ORN). Our objective was to identify factors that predispose to the development of ORN of the jaw. This was a retrospective, hospital-based, case-control study involving patients with head and neck cancer who had been treated with ≥ 60 Gy external radiotherapy (RT) to the jaw. A total of 19 cases of ORN and 43 controls were included. The patients' demographic data, tumor type, staging, treatment and outcome information, and pre-treatment oral status were collected. Univariate analysis showed that the oral cavity/oropharynx sites were associated with 9.77-fold increased risk of ORN development compared to other sites (p = 0.005). Being an active smoker was associated with 3.95-fold increased risk of ORN development (p = 0.01). A tendency towards increased risk of ORN was observed particularly when tooth extraction occurred after RT (odds ratio (OR): 3.04; p = 0.08). Multivariable analysis showed that tumor site was the only significant risk factor (OR: 21.03, p = 0.01). The oral and oropharyngeal primary site is an important risk factor for ORN. Dental extraction, which did not occur in 28% of the sample, was not an essential event for ORN development.

Fatores de risco associados à osteorradionecrose dos maxilares em pacientes com câncer de cavidade oral e orofaringe / Risk factors associated with osteoradionecrosis of the mandible in patients with cancer pf oral cavity and oropharynx

Introdução: A osteorradionecrose dos maxilares (ORN) é uma conhecida complicação relacionada à radioterapia, tendo grande impacto e podendo acometer indivíduos submetidos a radioterapia para tratamento de câncer da cavidade oral associado a uma condição dental desfavorável. Objetivo: Este estudo teve como objetivo avaliar e determinar a influência de fatores sociodemográficos e clínicos associados à ORN em indivíduos com câncer de cavidade oral e orofaringe submetidos a radioterapia atendidos no Departamento de Odontologia do Hospital de Câncer de Barretos entre os anos de 2007-2017. Material e método: Trata-se de um estudo caso-controle com coleta de dados retrospectivos em prontuários. Resultado: Os dados coletados correspodem a 83 prontuários selecionados, sendo 31 correspondentes ao grupo caso e 52 correspondentes ao grupo controle. Evidenciou-se uma média (desvio padrão) de idade para indivíduos dos grupos caso e controle de 65,44 (7,49) e 65,02 (10,08), respectivamente. Em ambos os grupos houve predominância do sexo masculino. A média (desvio padrão) do intervalo entre a última sessão de radioterapia e a data do diagnóstico de ORN foi de 26,42 (27,51) meses. A presença de doença periodontal no diagnóstico [OR=6,253; (IC95%1,25-31,12; p=0,025)] e exodontia [OR = 6,148; (IC95%) 1,14-26,23; p= 0,014) após radioterapia resultou em uma maior chance de desenvolver a ORN. Conclusão: A partir dos resultados obtidos, conclui-se que os principais fatores de risco para desenvolvimento da ORN em indivíduos com câncer de cavidade oral e orofaringe são exodontia após radioterapia e presença de periodontite no diagnóstico.

Introduction: Osteoradionecrosis of the mandible (ORNM) is a well-known complication related to radiotherapy that can affect patients undergoing radiotherapy to treat oral cavity cancer associated with an unfavorable dental condition. Objective: This study aimed to assess and determine the influence of sociodemographic and clinical factors associated with osteoradionecrosis on patients with cancer of oral cavity and oropharynx undergoing radiotherapy treated at the Department of Dentistry of the Barretos Cancer Hospital between 2007- 2017. Materials and method: This is a case-control study with retrospective data collection from medical records. Result: The data were collected from 83 medical records, 31 corresponding to the case group and 52 corresponding to the control group. The patients in the case and control groups were aged in average (standard deviation) 65.44 (7.49) and 65.02 (10.08) years, respectively. Both groups had a predominance of male individuals. The mean (standard deviation) interval between the last radiotherapy session and the date of osteoradionecrosis diagnosis was 26.42 (27.51) months. The presence of periodontal disease at diagnosis [OR = 6,253; (95% CI 1.25-31.12; p = 0.025)] and tooth extraction [OR = 6.148; (95% CI) 1.14-26.23; p = 0.014] after radiotherapy resulted in greater chances of developing osteoradionecrosis. Conclusion: Based on our results, extraction after radiotherapy and the presence of periodontitis in the diagnosis of patients with cancer of oral cavity and oropharynx are the main risk factors for the development of osteoradionecrosis.

Secondary primary tumor mimicking osteoradionecrosis

ABSTRACT Nasopharyngeal carcinoma (NPC) is a malignant tumor rarely found in the head and neck, representing about 1% of all malignancies. The main treatment for NPC is radiation therapy, which is often given in combination with chemotherapy. However, such treatment may lead to long‐term complications, including second primary tumors (SPTs) and osteoradionecrosis (ORN). Both complications have similar radiological characteristics, which can lead to erroneous diagnoses. This paper describes a case of a second primary tumor in a patient after 20 years of radiotherapy in the area where a previous extraction was performed, mimicking an osteoradionecrosis process.

Evaluation of hyperbaric oxygen therapy for the osteoradionecrosis of the jaws: Meta-analysis / 华西口腔医学杂志

OBJECTIVES@#This study was performed to investigate the effects of hyperbaric oxygen and other approaches for treating the osteoradionecrosis of the jaws (ORNJ) systematically.@*METHODS@#According to the preset inclusion and exclusion criteria, randomized controlled trials and cohort studies on hyperbaric oxygen in the treatment of ORNJ were screened, and foreign language databases such as PubMed, EMBASE, and Cochrane library were searched via a computer; Chinese databases such as CNKI, VIP, Wanfang data, and CBM were searched from the established database to September 2020. Relevant books were searched manually to collect all literatures on the efficacy of hyperbaric oxygen and its related therapies in ORNJ treatment. Two researchers were independent and mutually blind, the papers were selected, data were collected, and the bias risk was evaluated. If any difference was detected, it would be decided by discussion or arbitrated by a third party. The data related to the efficacy of hyperbaric oxygen and its related therapy in the treatment of the ORNJ were extracted, and the Revman5.4 software was used for Meta-analysis. In case of large heterogeneity, sensitivity analysis was performed. A funnel chart was used to evaluate possible publication bias qualitatively.@*RESULTS@#Four randomized controlled trials and seven cohort studies were included in Meta-analyses. In ORNJ treatment, no significant differences between the group subjected to hyperbaric oxygen and both surgery and antibiotics and the group that underwent both surgery and antibiotics (RR=1.16, 95%CI: 0.86~1.58, @*CONCLUSIONS@#Hyperbaric oxygen therapy cannot replace surgery and antibiotic therapy. Hyperbaric oxygen therapy is not superior to antibiotics and antifibrotic drugs, but the benefits of antifibrotic drugs should be further explored.

Effects of different irradiators on the establishment of osteoradionecrosis model of rat mandible / 华西口腔医学杂志

OBJECTIVES@#To compare the effects of different irradiators on the establishment of osteoradionecrosis of jaw model (ORNJ) to explore an ideal modeling method.@*METHODS@#A total of 33 adult SD rats were included and randomly divided into three groups according to the radiation equipment, namely, the blank control (CN, 3 rats), group A (linear accelerator irradiation, 15 rats), and group B (small-animal irradiator irradiation, 15 rats). Groups A and B were irradiated with daily fractions of 7, 8, and 9 Gy for 5 days and further divided into three subgroups as follows: group A@*RESULTS@#At 3 weeks after dental extractions, complete gingival healing was found in the regions of dental extractions in groups A@*CONCLUSIONS@#Small-animal irradiator irradiation is an ideal device for establishing ORNJ model.

Abordagem Cirúrgica de Osteorradionecrose Mandibular Causada por Fratura Idiopática / Surgical Approach of Mandible Osteoradionecrosis Caused by Idiopathic Fracture / Abordaje Quirúrgico de Osteorradionecrosis Mandibular Causada por Fractura Idiopática

Introdução: A osteorradionecrose acomete de 1% a 6% dos pacientes submetidos à radioterapia e é considerada a complicação oral mais grave advinda dessa modalidade terapêutica. Relato do caso: Trata-se de um homem, 65 anos, com diagnóstico de carcinoma de células escamosas em assoalho bucal esquerdo, tratado com cirurgia e radioterapia adjuvante. Na avaliação odontológica inicial, não foram observadas alterações clínicas ou radiográficas. Duas semanas após o término da radioterapia, o paciente relatou ter acordado com dor intensa em mandíbula, sem relato de trauma ou queda. A radiografia panorâmica evidenciou fratura no corpo mandibular esquerdo, sugerindo fratura idiopática durante o sono. Após dez dias, houve exposição óssea intraoral do coto distal e preconizou-se tratamento conservador com analgesia, osteotomia superficial sob anestesia local e antibioticoterapia profilática. O paciente evoluiu com secreção purulenta, fístula extraoral e eliminação de sequestro ósseo, após cinco meses, confirmando o diagnóstico de osteorradionecrose. Diante desse quadro, após 11 meses do diagnóstico da fratura, optou-se pela intervenção cirúrgica de mandibulectomia redutora de coto distal. Depois de sete meses de acompanhamento pós-cirúrgico, o paciente encontra-se sem evidências clínicas e radiográficas de osteorradionecrose. Conclusão: O tratamento da osteorradionecrose é considerado desafiador para os dentistas que lidam com essa sequela da radioterapia. Portanto, destaca-se a importância da capacitação do dentista para atuar em todas as etapas do tratamento oncológico

Introduction: Osteoradionecrosis of the jaws affects 1% to 6% of patients undergoing radiotherapy and is considered the most severe oral complication resulting from this therapeutic modality. Case report: This is a 65-year-old man diagnosed with squamous cell carcinoma in the left oral floor, treated with surgery and adjuvant radiotherapy. In the dental evaluation, no clinical or radiographic changes were observed. Two weeks after the radiotherapy, the patient reported severe pain in the mandible, with no report of trauma or fall. The panoramic radiograph showed a fracture in the left mandibular body, suggesting an idiopathic fracture while asleep. After ten days, there was intraoral bone exposure of the distal portion of the mandible and conservative treatment with analgesia, superficial osteotomy under local anesthesia and prophylactic antibiotic therapy was performed. The patient evolved with purulent secretion, extraoral fistula and elimination of bone sequestration, after five months, confirming the diagnosis of osteoradionecrosis. Thereby, 11 months after the fracture diagnosis, the patient underwent a surgical intervention with partial mandibulectomy of the distal portion. After seven months of post-surgical follow-up, the patient presents neither clinical or radiographic evidence of osteoradionecrosis. Conclusion: The treatment of osteoradionecrosis is considered challenging for dentists who deal with this side effect of radiotherapy. Therefore, the importance of training the dentist to work in all stages of cancer treatment is highlighted.

Introducción: La osteorradionecrosis afecta del 1% al 6% de los pacientes sometidos a radioterapia y se considera la complicación oral más grave resultante de esta modalidad terapéutica. Relato del caso: Hombre, 65 años, diagnosticado con carcinoma de células escamosas en el suelo de boca izquierdo, tratado con cirugía y radioterapia adyuvante. La evaluación odontológica no presentó alteraciones clínicas o radiográficas. Dos semanas después de concluir la radioterapia, él informó haber despertado con un fuerte dolor en la mandíbula, sin historia de trauma o caída. La radiografía panorámica mostró una fractura en el cuerpo mandibular izquierdo, lo que sugirió una fractura idiopática durante el sueño. Diez días después, hubo exposición ósea intraoral del muñón distal y fue empleado tratamiento conservador con analgesia, osteotomía superficial bajo anestesia local y antibiótico profiláctico. El paciente evolucionó con secreción purulenta, fístula extraoral y eliminación de secuestro óseo, pasados cinco meses, confirmando el diagnóstico de osteorradionecrosis. Así, pasados 11 meses del diagnóstico de fractura, fue indicada intervención quirúrgica de mandibulectomía reductora del muñón distal. Después de siete meses de la cirugía, no hay evidencias clínicas o radiográficas de osteorradionecrosis. Conclusión: El tratamiento de la osteorradionecrosis se considera un desafío para los dentistas que se ocupan de esta secuela de la radioterapia. Por lo tanto, se destaca la importancia de capacitar al dentista, para que trabaje en todas las etapas del tratamiento oncológico

Osteoradionecrosis in a Patient Submitted to Head and Neck Radiotherapy: A Case Report / Osteoradionecrosis en un Paciente Sometido a Radioterapia de Cabeza y Cuello: Reporte de un Caso

ABSTRACT: Radiotherapy applies ionizing radiation at predetermined doses for a limited period of time in order to destroy tumors. The oral cavity, which has a high rate of cell renewal, is affected by the side effects of radiotherapy including osteoradionecrosis (ORN). This condition occurs due to irradiated bone tissue that becomes devitalized and exposed in the oral cavity. Conservative therapies are recommended for ORN lesions that are not extensive or in an early stage. Surgical intervention is necessary for extensive areas affected by necrosis. This study reports a case of ORN in the left mandibular body which resulted in a pathological fracture. The treatment consisted of segmental mandibulectomy and the use of a reconstruction plate. Also, low-level laser therapy around bone exposure was performed. After surgery, the patient underwent 6 months of follow-up and was satisfied with the outcome. However, the patient died before control of ORN was achieved due to a heart attack.

RESUMEN: La radioterapia aplica radiación ionizante a dosis predeterminadas durante un período de tiempo limitado para destruir tumores. La cavidad oral, que tiene una alta tasa de renovación celular, se ve afectada por los efectos secundarios de la radioterapia, incluida la osteorradionecrosis (ORN). Esta condición se produce debido al tejido óseo irradiado que se desvitaliza y expone en la cavidad oral. Se recomiendan terapias conservadoras para las lesiones de ORN que no son extensas o en una etapa temprana. La intervención quirúrgica es necesaria para áreas extensas afectadas por necrosis. Este estudio reporta un caso de ORN en el cuerpo mandibular izquierdo que resultó en una fractura patológica. El tratamiento consistió en mandibulectomía segmentaria y el uso de una placa de reconstrucción. Además, se realizó una terapia con láser de bajo nivel alrededor de la exposición ósea. Después de la cirugía, el paciente se sometió a 6 meses de seguimiento y quedó satisfecho con el resultado. Sin embargo, el paciente falleció antes de que se lograra el control de ORN debido a un ataque cardíaco.

Prevenção e manejo terapêutico da osteoradionecrose dos maxilares: revisão de literatura / Prevention and therapeutic management of osteoradionecrose of maxilars: literature review

O objetivo desse estudo foi revisar a literatura e enfatizar os aspectos relacionados ao manejo preventivo e terapêutico da osteorradionecrose dos maxilares. Realizou-se revisão bibliográfica não sistemática, descritiva e qualitativa nas plataformas de pesquisa Scielo, Pubmed e Medline, utilizando os descritores, osteoradionecrosis/osteoradionecrose e/ou radiotherapy/radioterapia e/ou jaw/arcada maxilares. Os critérios de inclusão foram: artigos publicados em inglês, espanhol ou português, pesquisas clínicas ou relatos de casos abordando tratamento com radioterapia de cabeça e pescoço e artigos publicados entre 1980-2018, excluindo da pesquisa trabalhos experimentais em animais, artigos publicados na forma de nota técnica ou carta ao editor e artigos baseados em opinião de especialistas. Baseando-se nos critérios de pesquisa, foram selecionados 56 artigos. A radioterapia é eficaz e amplamente utilizada como terapia nas neoplasias malignas de cabeça e pescoço, entretanto produz efeitos colaterais, sendo a osteorradionecrose uma das mais graves. Na maioria dos casos, progride lentamente, tornando-se extensa e dolorosa, suas manifestações tardias compreendem infecção e fratura óssea patológica. Nas últimas décadas, várias opções profiláticas ou terapêuticas foram consideradas no manejo da osteorradionecrose, sendo as mais relatadas: medidas de suporte, antibioticoterapia/antibioticoprofilaxia, pentoxifilina e tocoferol, oxigênio hiperbárico e ressecção cirúrgica com enxerto ósseo. A adequação do meio bucal e cirurgias orais antes de iniciar a radioterapiaainda é o tratamento ideal para prevenir a osteorradionecrose. A antibioticoterapia e/ou antibioticoprofilaxia sistêmica, anti-sépticos locais, pentoxifilina e tocoferol e oxigênio hiperbárico são os tratamentos mais relatados na literatura e que buscam minimizar a incidência da osteorradionecrose após procedimentos cirúrgicos odontológicos em pacientes submetidos a tratamentos de radioterapia(AU)

The purpose of this paper was to review the literature and to emphasize the aspects related to the preventive and therapeutic management of osteorradionecrosis of the jaws. Methods: A nonsystematic, descriptive and qualitative bibliographic review was performed on the Scielo, Pubmed and Medline research platforms, using the descriptors, osteoradionecrosis/osteoradionecrose and/or radiotherapy/radioterapia and/or jaw/maxilares. The inclusion criteria were: articles published in English, Spanish or Portuguese, clinical research or reports of cases approaching of treatment with head and neck radiotherapy and articles published between 1980- 2018, excluding from the research experimental study on animals, articles published in the form of technical note or letter to the editor and articles based on expert opinion. Results: Based on the search criteria, 56 articles were selected. Radiotherapy is effective and widely used as a therapy for malignant head and neck neoplasias, however it produces side effects, being osteoradionecrosis the most severe one. In most cases, it progresses slowly, becoming extensive and painful; its late manifestations comprise infection and pathological bone fracture. In the last decades, several prophylactic or therapeutic options have been considered in the management of osteoradionecrosis, being reported: supportive measures, antibiotic therapy/prophylaxis, pentoxifylline, tocopherol, hyperbaric oxygen and surgical resection with bone graft. Conclusion: The suitability of the oral cavity and oral surgery before starting the radiation therapy is still an ideal treatment to prevent osteoradionecrosis. Antibiotic therapy/prophylaxis, local antiseptics, pentoxifylline, tocopherol and hyperbaric oxygen are the most commonly reported treatments in the literature and seek to minimize the incidence of osteoradionecrosis after dental surgical procedures in patients undergoing radiation therapy(AU)

New Therapeutic Approaches to Osteoradionecrosis: Literature Review / Novas Abordagens Terapêuticas para a Osteorradionecrose: uma Revisão de Literatura

Radiotherapy is an important treatment of oral and maxillofacial malignancies. Among the various effects of this locoregional therapy, osteoradionecrosis (ORN) plays a prominent role due to its physical and psychological impact on cancer patients. In the literature, the therapeutic approach of ORN varies from a conservative to invasive surgery treatment. Objective: collect in the scientific literature, concise and current information about the benefits of using these therapies in the ORN. The present literature review selected articles based on the titles that addressed osteoradionecrosis treatment, as well as the evaluation systems adopted. After previous analysis, 22 relevant articles were included on the proposed theme. According to the literature, several hypotheses have been established to explain the etiopathogenesis of ORN, as numerous evaluation systems have been developed in the last years. Regarding the main therapeutic modalities used, new less invasive therapies have acquired space, such as ozone therapy, laser therapy associated with photodynamic therapy and drugs, such as vitamin, antifibrotic and anti-resorptive. However, in spite of the promising results, new randomized clinical trials have to be performed in an attempt to discover the real effectiveness of these therapies in the ORN. Therefore, it becomes a challenging issue for dental surgeons, since it requires the constant monitoring and long term of these patients, due to the risk of progression or recurrence of this condition. (AU)

A radioterapia compreende um tratamento importante no tratamento de tumores malignos orais e maxilofaciais. Dentre os diversos efeitos oriundos desta terapia locoregional, a osteorradionecrose (ORN) apresenta um papel de destaque devido ao seu impacto físico e psicológico ao paciente oncológico. A abordagem terapêutica da ORN pode variar do tratamento conservador ao tratamento invasivo através da cirurgia. Objetivo coletar na literatura científica informações concisas e atuais acerca dos benefícos do uso dessas terapias na ORN. A presente revisão narrativa de literatura teve a seleção de artigos com base nos títulos que abordaram as terapias empregadas na osteorradionecrose, bem como os sistemas de avaliação adotados. Após análise prévia, foram incluídos 39 artigos relevantes sobre a temática proposta. De acordo com a literatura, várias hipóteses foram estabelecidas para explicar a etiopatogenia da ORN, assim como inúmeros sistemas de avaliação foram desenvolvidos nos últimos anos. Com relação as principais modalidades terapêuticas empregadas, novas terapias menos invasivas têm adquirido espaço, a exemplo da ozonioterapia, laserterapia associada à terapia fotodinâmica e medicamentos antioxidantes, antifibróticos e antireabsortivos. Todavia, apesar dos resultados promissores, novos ensaios clínicos precisam ser realizados, para se descobrir a real eficácia dessas terapias na ORN. Portanto, torna-se uma questão desafiadora para os Cirurgiões-dentistas, uma vez que requer o monitoramento constante e a longo prazo desses pacientes, devido ao risco de progressão ou recidiva desta afecção. (AU)

Prevention and treatment of osteoradionecrosis of the jaws / 口腔疾病防治

@#Radioactive jaw necrosis is a serious complication of head and neck radiotherapy. This complication's main characteristics are chronic necrosis and infection, and its clinical manifestations are local pain, mouth opening re'striction, speech disorder, dysphagia, exposure of dead bone, prolonged healing of facial and neck soft tissue fistula, and even pathological fracture, which brings great pain to the patient's body and mind. Radioactive jaw necrosis has become a clinical problem in the field of medicine, specifically for maxillofacial surgery of the external head and neck. The pathogenesis of radiation-induced jaw necrosis is still unclear, but high radiotherapy dose, extraction of teeth after radio-therapy and surgical trauma are recognized as high-risk factors. The diagnosis of radiation-induced jaw necrosis needs to be combined with the patient's radiotherapy history, clinical symptoms and imaging examination. Conservative or sur-gical treatment should be selected according to its clinical classification and stages, and the prevention of radiation-in- duced jaw necrosis should be emphasized. The key points are to remove dental caries, residual roots and crowns before radiotherapy; improve radiotherapy technology; and take preventive measures against high-risk factors. In recent years, the diagnosis and treatment of radiation-induced jaw necrosis has gradually become standardized and individualized.This article reviews the progress of treatment and research on radiation-induced jaw necrosis at home and abroad in terms of its definition, etiology, risk factors, diagnosis, treatment and prevention to provide reference for clinical treat-ment.

Difficulties and prevention and management of serious complications in surgical treatment of osteoradionecrosis of jaw / 口腔疾病防治

@#Osteoradionecrosis of the jaw (ORNJ) is a common complication after radiotherapy for head and neck malignant tumors. Surgery is the main treatment method for ORNJ with large lesions. In the case of serious maxillofacial and cervical soft and hard tissue damage caused by radiation, surgical treatment may have some difficulties and risks. In this paper, we discuss the main points for indication selection and treatment as well as surgical difficulties and their causes, including local inflammation and radiation injury during the operation, timing of bone defect reconstruction, condylar preservation, selection of recipient vessels, implant bed treatment, common complications of ORNJ operations (i.e., wound healing and nerve injury), severe complications (i.e., vascular crisis and tissue flap necrosis), pulmonary infection, cerebral pulmonary embolism, important vascular rupture, and severe psychological trauma, including its prevention and treatment. This information will enable clinicians to fully understand the various difficulties and risks that may be encountered during the ORNJ operation and will minimize serious complications, ensure the life, health and safety of the patients, and provide a reference for improvement of the clinical efficacy of ORNJ treatment.

Application of virtual surgical planning in the surgical treatment of osteoradionecrosis of mandible / 口腔疾病防治

Objective @#To analyze the value of virtual surgical planning in the surgical treatment of osteoradionecrosis of the mandible and to provide a reference for clinical practice.@*.Methods @#From September 2017 to June 2018, 13 patients with mandibular osteoradionecrosis were evaluated preoperatively using the 3D virtual surgery software CMF Proplan 2.0. The surgical guide was designed and 3D printed. Bone resection, fibula shaping and bone graft localization were completed during the operation. In some cases, implants were implanted at the same time, and denture restoration was completed 3 to 6 months after surgery. Patients’ general information, perioperative data, and efficacy evaluation were analyzed.@*Results@#All patients underwent surgery successfully. The survival rate of the free fibula musculocutaneous flap was 100% (13/13), and one patient had complications (partial necrosis at the edge of the flap). The follow-up period was 7 to 15 months, and the median time was 10 months. All patients achieved a healing effect. The number of cases with an increase in mouth opening ≥ 1 cm, 0.5 cm ≤ mouth opening increase < 1 cm, and mouth opening increase < 0.5 cm were 5, 6, and 2, respectively. An imaging examination showed that 12 patients had good bone healing, and 1 patient did not completely heal 7 months after operation. The denture restoration was 92.3% (12/13), of which 3 cases were implanted and repaired at the same time. The average chewing efficiency was 56.11% ± 7.12% (42.03%-67.83%).@*Conclusion@#Virtual surgical planning is an effective method for the surgical treatment of mandibular osteoradionecrosis, which can reduce the risk of surgery and more effectively perform mandibular shape and function repair.

Retrospective study of osteoradionecrosis in the jaws of patients with head and neck cancer

OBJECTIVES: Osteoradionecrosis (ORN) is one of the most severe complications resulting from radiotherapy (RT) in patients with head and neck cancer (HNC). It is characterized by persistent exposed and devitalized bone without proper healing for greater than 6 months after a high dose of radiation in the area. To describe the profile and dental management of ORN in HNC patients undergoing RT in an oncological clinical research center. MATERIALS AND METHODS: A retrospective descriptive study was performed to analyze dental records from HNC patients with ORN treated at an oncological clinical research center from 2013 to 2017. A total of 158 dental records for HNC patients were selected from a total of 583 records. Afterwards, this number was distributed to three examiners for manual assessments. Each examiner was responsible for selecting dental records that contained an ORN description, resulting in 20 dental records. RESULTS: Mean patient age was 60.3 years with males being the most affected sex (80.0%). The most affected area was the posterior region of the mandible (60.0%) followed by the anterior region of the mandible (20.0%) and the posterior region of the maxilla (10.0%). The factors most associated with ORN were dental conditions (70.0%) followed by isolated systemic factors (10.0%) and tumor resection (5.0%). There was total exposed bone closure in 50.0% of cases. The predominant treatment was curettage associated with chlorhexidine 0.12% irrigation (36.0%). CONCLUSION: Poor dental conditions were related to ORN occurrence. ORN management through less invasive therapies was effective for the closure of exposed bone areas and avoidance of infection.

Influencing factors of quality of life of patients with osteoradionecrosis of the jaws / 现代临床护理

Objective To investigate the level and influencing factors of quality of life in patients with osteoradionecrosis of the jaws (ORNJ) in order to provide theory basis for nursing intervention. Methods Ninety-five patients hospitalized from January 2015 to Febury 2017 and participated in the investigation by a convenient sampling method. The functional assessment of cancer therapy-head and neck (FACT-H&N), social support rating scale (SSRS) and general information questionnaire were used to assess the quality of life, social support and basic information in ORNJ patients in our hospital respectively. Results The score of quality of life was (79.99 ±15.72). The index value of common module of quality of life was higher than that of additional concern. The average scores of each dimension of common module from low to high were as follows: functional well-being, social/family well-being, physical well-being and emotional well-being. The multiple linear regression analysis showed that the influencing factors of quality of life were social support, severe mouth opening difficulty (grade Ⅲ and Ⅳ), the course of primary disease (3 ～5 years, 5 ～10 years), which explained 35.6％variation in the quality of life. Conclusions The quality of life of ORNJ patients is generally lower than that of other head and neck cancer patients. The social support, severe mouth opening difficulty and course of primary disease can affect the patients' quality of life.The smaller the mouth opening (≤1 cm), the longer the course of primary disease (3～5 years) and the worse the quality of life is. Thus, nursing staff should pay attention to the quality of life of ORNJ patients and give prospective nursing intervention to improve the quality of life according to the characteristics of the development of the disease.

Osteonecrosis of the jaws: a review and update in etiology and treatment / Osteonecrose da mandíbula: revisão e atualização em etiologia e tratamento

Abstract Introduction Osteonecrosis of the jaws can result either from radiation, used in radiotherapy for treatment of malignant tumors, or medications used for bone remodeling and anti-angiogenesis such as bisphosphonates. These conditions can be associated with triggering factors such as infection, trauma and decreased vascularity. The management of patients with osteonecrosis of the jaws requires caution since there is no specific treatment that acts isolated and decidedly. However, different treatment modalities can be employed in an associated manner to control and stabilize lesions. Objective To review the current knowledge on etiology and management of osteonecrosis of the jaws, both radio-induced and medication-related, aiming to improve knowledge of professionals seeking to improve the quality of life of their patients. Methods Literature review in PubMed as well as manual search for relevant publications in reference list of selected articles. Articles in English ranging from 1983 to 2017, which assessed osteonecrosis of the jaws as main objective, were selected and analyzed. Results Infections, traumas and decreased vascularity have a triggering role for osteonecrosis of the jaws. Prophylactic and/or stabilizing measures can be employed in association with therapeutic modalities to properly manage osteonecrosis of the jaws patients. Conclusion Selecting an appropriate therapy for osteonecrosis of the jaws management based on current literature is a rational decision that can help lead to a proper treatment plan.

Resumo Introdução A osteonecrose da mandíbula pode resultar da radiação usada na radioterapia para tratamento de tumores malignos ou de medicamentos usados para remodelação óssea e antiangiogênese, como os bifosfonatos. Essas condições podem ser associadas a fatores desencadeantes, como infecção, trauma e diminuição da vascularização. O tratamento de pacientes com osteonecrose da mandíbula requer cautela, pois não existe um tratamento específico que atue de maneira isolada e decisiva. No entanto, diferentes modalidades de tratamento podem ser empregadas de forma associada para controlar e estabilizar lesões. Objetivo Revisar os conhecimentos atuais sobre a etiologia e o tratamento da osteonecrose da mandíbula, tanto induzidos por radiação quanto relacionados à medicação, para melhorar o conhecimento dos profissionais que busquem a qualidade de vida de seus pacientes. Método Revisão de literatura na base de dados PubMed, bem como pesquisa manual de publicações relevantes na lista de referência de artigos selecionados. Foram selecionados e analisados artigos em inglês publicados de 1983 a 2017, que avaliaram osteonecrose da mandíbula como seu principal objetivo. Resultados Infecções, traumas e diminuição da vascularização são fatores desencadeantes da osteonecrose da mandíbula. Medidas profiláticas e/ou estabilizadoras podem ser usadas em associação com modalidades terapêuticas para o tratamento adequado de pacientes com osteonecrose da mandíbula. Conclusão Selecionar uma terapia apropriada para o tratamento de osteonecrose da mandíbula com base na literatura atual é uma decisão racional que pode ajudar a estabelecer a um plano de tratamento adequado.

Treatment of Fungal Empyema Combined with Osteoradionecrosis by Thoracoplasty and Myocutaneous Flap Transposition

We report the rare case of a 58-year-old woman who was diagnosed with fungal empyema thoracis combined with osteoradionecrosis. After 32 months of home care followed by open window thoracostomy, thoracoplasty with serratus anterior muscle transposition and a latissimus dorsi myocutaneous flap was performed successfully. Although thoracoplasty is now rarely indicated, it is still the treatment of choice for the complete obliteration of thoracic spaces.