Osteorradionecrose dos maxilares em pacientes portadores de câncer de cabeça e pescoço - Overview de revisões sistemáticas / Osteoradionecrosis and its treatment protocols in patients with head and neck cancer - overview of systematic reviews

Os pacientes portadores de câncer de cabeça e pescoço realizam tratamento, de radioterapia podendo ou não estar associados à quimioterapia e/ou cirurgias. A qualidade de vida dos mesmos é afetada em função dos efeitos colaterais causados pelos tratamentos. Mucosite, hiposalivação, perda do paladar, trismo e osteorradionecrose são os efeitos colaterais que mais acomentem os pacientes em tratamento para câncer de cabeça e pescoço. A osteorradionecrose é considerada um evento tardio e a maior complicação pós tratamento de radioterapia. Foi realizada uma busca sistemática nas bases de dados eletrônicas MEDLINE / PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Open Gray e busca manual, sem restrição de idioma e tempo. Os critérios de elegibilidade foram os seguintes: 1) ser revisão sistemática; 2) abordar sobre os efeitos orais e complicações após quimioterapia e/ou radioterapia em pacientes adultos portadores de câncer de cabeça e pescoço e 3) RS baseadas em estudos clínicos prospectivos/ retrospectivos e ECR (estudo clínico randomizado). A elegibilidade foi determinada de acordo com os critérios de exclusão para:1) RS que descrevessem a o tratamento para as sequelas da ORN; 2) as RS baseadas em relatos de casos ou estudos in vitro sobre ORN; 3) ORN em ossos não gnáticos (temporal); 4) não abordarem sobre incidência, tratamento ou prevenção da ORN e 5) revisão da classificação da ORN. Foram identificados 1321 artigos, mas apenas 13 foram considerados elegíveis. A fase de elegibilidade, qualidade metodológica (AMSTAR 2) foi conduzida por dois examinadores independentes e calibrados (RMS e GS), e um terceiro examinador (MSANM) foi consultado para a resolução de incongruências. O número de pacientes avaliados para o desenvolvimento de ORN ao longo do tratamento foi 33.762 sendo que desses, 2.094 desenvolveram a lesão, representando uma incidência de 6,2%. Quanto a localização a mandíbula é o local de maior acometimento. A exodontia após a radioterapia foi apontada como o maior fator causal para o desenvolvimento de ORN. A abordagem de tratamento para a ORN com pentoxifilina e tocoferol demonstrou eficácia superior em relação ao uso de antibioticoterapia e câmera hiperbárica. Baseado no risco de viés, é baixo o nível atual de evidência para as abordagens preventivas e curativas da ORN.

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

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.

Exodontia atraumática associada a elásticos ortodônticos em pacientes submetidos ao tratamento oncológico radioterápico: revisão de literatura / Atraumatic tooth extraction associated with orthodontic elastics in patients submitted to radiotherapy oncological treatment: literature review

Introdução: O câncer está atualmente entre as cinco causas mais frequentes de mortes no planeta, tudo isso devido a hábitos deletérios ou predisposição genética. O câncer de boca ocupa uma posição de destaque nesse panorama e necessita de uma atenção odontológica especial, devido à associação da perda dentária com o tratamento oncológico. Objetivo: O objetivo deste trabalho foi fazer uma análise biológica dos processos desencadeados pelo tratamento radioterápico e apresentar um método alternativo de exodontia seguro para os pacientes oncológicos. Revisão da literatura: O tratamento oncológico radioterápico desencadeia uma série de complicações bucais que eventualmente exigirão a exodontia, entre eles: osteorradionecrose, hipossalivação, cáries, doença periodontal, entre outros. Discussão: A exodontia com elásticos ortodônticos consiste no envolvimento dentário na altura cervical com os elásticos causando uma esfoliação lenta, gradual e mais atraumática possível da raiz, esse processo leva em torno de 5 a 8 semanas. Esta técnica associada a um bom pós-operatório garantirá uma cicatrização adequada aumentando significativamente as chances de um prognóstico positivo. Conclusão: Os resultados dessa associação de técnicas são seguros e diminuem os riscos de complicações pós-operatória, garantindo assim, uma recuperação sem maiores problemas ao paciente.

Introduction: Cancer is currently among the five most common causes of death worldwide, resulting from harmful habits or genetic predisposition. Oral cancer plays a major role in this scenario and requires special dental care due to the association of tooth loss with cancer treatment. Aim: This study aimed at the biolo-gical analysis of the processes triggered by radiotherapy treatment and presentation of an alternative method for safe tooth extraction in cancer patients. Literature review: Cancer radiotherapy treatment triggers a series of oral complications that will eventually require tooth extraction, for example, osteoradionecrosis, hyposaliva-tion, caries, and periodontal disease. Discussion: Tooth extraction with orthodontic elastics involves the tooth at the cervical height with elastics allowing a slow, gradual, and less traumatic exfoliation of the root; this process takes approximately 5 to 8 weeks. This technique is as-sociated with a good postoperative recoveryand ensures adequate healing, significantly increasing the likelihood of a positive prognosis. Conclusion: These techniques are safe and decrease the risk of postoperative complications, thus ensuring recovery without major problems for the patient.

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.

The effects of pentoxifylline and tocopherol in jaw osteomyelitis

OBJECTIVES: Pentoxifylline (PTX) is a methylxanthine derivative that has been implicated in the pathogenesis of peripheral vessel disease and intermittent lameness. The purpose of this study was to investigate the effect of PTX and tocopherol in patients diagnosed with osteoradionecrosis (ORN), bisphosphonate-related osteonecrosis of the jaw (BRONJ), and chronic osteomyelitis using digital panoramic radiographs.MATERIALS AND METHODS: This study was performed in 25 patients who were prescribed PTX and tocopherol for treatment of ORN, BRONJ, and chronic osteomyelitis between January 2014 and May 2018 in Seoul National University Dental Hospital. Radiographic densities of the dental panorama were compared prior to starting PTX and tocopherol, at 3 months, and at 6 months after prescription. Radiographic densities were measured using Adobe Photoshop CS6 (Adobe System Inc., USA). Blood sample tests showing the degree of inflammation at the initial visit were considered the baseline and compared with results after 3 to 6 months. Statistical analysis was performed using the Mann–Whitney test and repeated measurement ANOVA using IBM SPSS 23.0 (IBM Corp., USA).RESULTS: Eight patients were diagnosed with ORN, nine patients with BRONJ, and the other 8 patients with chronic osteomyelitis. Ten of the 25 patients were men, average age was 66.32±14.39 years, and average duration of medication was 151.8±80.65 days (range, 56–315 days). Statistically significant increases were observed in the changes between 3 and 6 months after prescription (P<0.05). There was no significant difference between ORN, BRONJ, and chronic osteomyelitis. Only erythrocyte sedimentation rate (ESR) was statistically significantly lower than before treatment (P<0.05) among the white blood cell (WBC), ESR, and absolute neutrophil count (ANC).CONCLUSION: Long-term use of PTX and tocopherol can be an auxiliary method in the treatment of ORN, BRONJ, or chronic osteomyelitis in jaw.

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)

Terapia láser de baja frecuencia en el manejo del dolor en pacientes con osteonecrosis mandibular / Low level laser therapy in the management of pain in patients with osteonecrosis of the jaw

La terapia láser de baja frecuencia (TLBF) o fotobioestimulación es aquella que cuya luz provoca la regeneración y remodelación ósea, la restauración de la función neural, la disminución del dolor y la modulación del sistema inmune; esta terapia es un coadyuvante junto a la terapia conservadora y/o quirúrgica. Se considera un estándar de oro para el manejo del dolor en la osteonecrosis en aquellos pacientes que consumen o han consumido bifosfonatos como terapia para inhibir la resorción ósea. La Sociedad Americana de Investigación de Hueso y Minerales (SAIHM) definió la osteonecrosis mandibular como «un área de hueso expuesto en la región maxilofacial que no cicatriza dentro de las ocho semanas posteriores a la identificación, en un paciente que está recibiendo o ha estado expuesto a bifosfonatos y que no ha recibido radioterapia en la región craneofacial¼. En este reporte presentamos dos casos de pacientes con osteonecrosis mandibular relacionada a bifosfonatos tratados con TLBF. Se evaluó el dolor antes y después de la terapia con la escala visual análoga (EVA). Ambos casos tuvieron disminución del dolor al 100%. Se presentan los métodos de diagnóstico clínico y radiográfico, el tratamiento elegido y los resultados obtenidos (AU)

Low level laser therapy (LLLT) or photobiostimulation is one whose light causes bone regeneration and remodeling, restoration of neural function, reduction of pain, and modulation of the immune system; this therapy is an adjuvant together with conservative and / or surgical therapy. It is considered a gold standard for pain management in osteonecrosis in those patients who consume or have used bisphosphonates as antiresorptive therapy. The American Society for Bone and Mineral Research (ASBMR) defined osteonecrosis of the jaw as «an area of exposed bone in the maxillofacial region that does not heal within eight weeks after identification by a health care provider, in a patient who was receiving or had been exposed to a BP and who has not received radiation therapy to the craniofacial region¼. In this report we present two cases of patients with mandibular osteonecrosis related to bisphosphonates treated with LLLT. Pain before and after visual analogue scale (VAS) was evaluated. Both cases had pain reduction at 100%. The methods of clinical and radiographic diagnosis, the treatment chosen and the results obtained are presented (AU)

7-mm-long dental implants: retrospective clinical outcomes in medically compromised patients

OBJECTIVES: Dental implants shorter than 8 mm, called short dental implants (SDIs), have been considered to have a lower success rate than standard length implants. But recent studies have shown that SDIs have a comparable success rate, and implant diameter was more important for implant survival than implant length. Also, SDIs have many advantages, such as no need for sinus lifting or vertical bone grafting, which may limit use in medically compromised patients. MATERIALS AND METHODS: In this study, 33 patients with 47 implants 7-mm long were examined over the last four years. All patients had special medical history and were categorized into 3 groups: systemic disorders, such as diabetes mellitus (controlled or uncontrolled), mental disability, and uncontrolled hypertension; oral cancer ablation with reconstruction, with or without radiotherapy; diverse osteomyelitis, such as osteoradionecrosis and bisphosphonate-related osteonecrosis of the jaw. Most of these patients have insufficient residual bone quality due to mandible atrophy or sinus pneumatization. RESULTS: The implant diameters were 4.0 (n=38), 4.5 (n=8), and 5.0 mm (n=1). Among the 47 implants placed, 2 implants failed before the last follow-up. The survival rate of 7-mm SDIs was 95.74% from stage I surgery to the last follow-up. Survival rates did not differ according to implant diameter. The mean marginal bone loss (MBL) at 3 months, 1 and 2 years was significantly higher than at implant installation, and the MBL at 1 year was also significantly higher than at 3 months. MBL at 1 and 2 years did not differ significantly. CONCLUSION: Within the limitations of the present study, the results indicate that SDIs provide a reliable treatment, especially for medically compromised patients, to avoid sinus lifting or vertical bone grafting. Further, long-term follow-up is needed.

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.

Early diagnosis of jaw osteomyelitis by easy digitalized panoramic analysis / 대한악안면성형재건외과학회지

BACKGROUND: Osteomyelitis is an intraosseous inflammatory disease characterized by progressive inflammatory osteoclasia and ossification. The use of quantitative analysis to assist interpretation of osteomyelitis is increasingly being considered. The objective of this study was to perform early diagnosis of osteomyelitis on digital panoramic radiographs using basic functions provided by picture archiving and communication system (PACS), a program used to show radiographic images. METHODS: This study targeted a total of 95 patients whose symptoms were confirmed as osteomyelitis under clinical, radiologic, pathological diagnosis over 11 years from 2008 to 2017. Five categorized patients were osteoradionecrosis, bisphosphonate-related osteonecrosis of jaw (BRONJ, suppurative and sclerosing type), and bacterial osteomyelitis (suppurative and sclerosing type), and the control group was 117 randomly sampled. The photographic density in a certain area of the digital panoramic radiograph was determined and compared using the “measure area rectangle,” one of the basic PACS functions in INFINITT PACS® (INFINITT Healthcare, Seoul, South Korea). A conditional inference tree, one type of decision making tree, was generated with the program R for statistical analysis with SPSS®. RESULTS: In the conditional inference tree generated from the obtained data, cases where the difference in average value exceeded 54.49 and the difference in minimum value was less than 54.49 and greater than 12.81 and the difference in minimum value exceeded 39 were considered suspicious of osteomyelitis. From these results, the disease could be correctly classified with a probability of 88.1%. There was no difference in photographic density value of BRONJ and bacterial osteomyelitis; therefore, it was not possible to classify BRONJ and bacterial osteomyelitis by quantitative analysis of panoramic radiographs based on existing research. CONCLUSIONS: This study demonstrates that it is feasible to measure photographic density using a basic function in PACS and apply the data to assist in the diagnosis of osteomyelitis. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s40902-019-0188-2) contains supplementary material, which is available to authorized users.

Tc-99m hydroxymethylene diphosphonate scintigraphy, computed tomography, and magnetic resonance imaging of osteonecrosis in the mandible: Osteoradionecrosis versus medication-related osteonecrosis of the jaw

PURPOSE: To present characteristic findings of Tc-99m hydroxymethylene diphosphonate (HMDP) scintigraphy, computed tomography (CT), and magnetic resonance (MR) imaging for osteonecrosis in the mandible, especially osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ). MATERIALS AND METHODS: Thirteen patients with MRONJ and 7 patients with ORN in the mandible underwent Tc-99m HMDP scintigraphy, CT, and MR imaging (T1-weighted images [T1WI], T2-weighted images [T2WI], short inversion time inversion recovery images [STIR]), diffusion-weighted images [DWI], and apparent diffusion coefficient [ADC] mapping). The associations of scintigraphy, CT, and MR imaging findings with MRONJ and ORN were analyzed using the chi-square test with the Pearson exact test. RESULTS: Thirteen patients with MRONJ and 7 patients with ORN in the mandible showed low signal intensity on T1WI and ADC mapping, high signal intensity on STIR and DWI, and increased uptake on scintigraphy. Periosteal bone proliferation on CT was observed in 69.2% of patients with MRONJ (9 of 13) versus 14.3% of patients with ORN (1 of 7) (P=0.019). CONCLUSION: This study presented characteristic imaging findings of MRONJ and ORN on scintigraphy, CT, and MR imaging. Our results suggest that CT can be effective for detecting MRONJ and ORN.

The supraclavicular artery island flap: a salvage option for head and neck reconstruction / 대한악안면성형재건외과학회지

BACKGROUND: Some of head and neck cancer patients are in compromised general condition after ablation surgery and chemoradiation therapy, which makes secondary free tissue transfer quite challenging. Elderly cancer patients also have some risk for microvascular surgery with lengthened general anesthesia. In those cases, the pedicled flap vascularized by supraclavicular artery could be considered as an alternative to free flap. Despite several authors have demonstrated the clinical reliability of supraclavicular artery island flap (SCAIF), to date, SCAIF has not been widely used among reconstructive surgeon. In this article, we clarified vascular flow pattern and introduce simple surgical technique of SCAIF with a literature review. CASE PRESENTATION: Three patients who had underwent previous neck surgery and adjuvant therapy received maxillofacial reconstruction using SCAIF. It required only a few landmarks, flap harvesting was carried out, and the elapsed time gradually decreased to 15 min with experiences. There were no remarkable morbidities in both donor and recipient sites. CONCLUSION: SCAIF exhibited minimal anatomic variations and short learning curve of surgical techniques, which might be valuable reconstruction modality for beginning surgeon. And it can be beneficial option for the patients with vessel-depleted neck, medically compromised status for lengthened general anesthesia and failed free tissue transfer.

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.

Dental Problems Associated with Radiation Therapy / 대한연하장애학회지

Dental problems associated with radiation therapy are difficult to treat because of the irreversible nature of radiation therapy and permanent tissue damage. Common oral complications include oral mucosa ulceration, xerostomia, and radiation caries. Other oral complications found infrequently are mouth opening limitation and osteonecrosis of the jaw bone. The acute complication of oral ulceration is associated with dysphagia. In addition, delayed complications, such as xerostomia and dental caries, could lower the quality of life, particularly in terms of chewing and swallowing. The treatment of each complication is dependent on the condition and severity. Symptomatic treatment to relieve pain and discomfort is typical for oral complications. Surgical and radical resection is required for the advanced stage of osteoradionecrosis. In this review, oral complications and their treatments are suggested for clinical guidance.

Osteoradionecrosis of the jaws: case series treated with adjuvant low-level laser therapy and antimicrobial photodynamic therapy

Abstract Background: Osteoradionecrosis of the jaw (ORNJ) is the most severe and complex sequel of head and neck radiotherapy (RT) because of the bone involved, it may cause pain, paresthesia, foul odor, fistulae with suppuration, need for extra oral communication and pathological fracture. We treated twenty lesions of ORNJ using low-level laser therapy (LLLT) and antimicrobial photodynamic therapy (aPDT). The objective of this study was to stimulate the affected area to homeostasis and to promote the healing of the oral mucosa. Methods: We performed aPDT on the exposed bone, while LLLT was performed around the bone exposure (red spectrum) and on the affected jaw (infrared spectrum). Monitoring and clinical intervention occurred weekly or biweekly for 2 years. Results: 100% of the sample presented clinical improvement, and 80% presented complete covering of the bone exposure by intact oral mucosa. Conclusion: LLLT and aPDT showed positive results as an adjuvant therapy to treat ORNJ.

Medication-related osteonecrosis of the jaw, osteoradionecrosis, and osteomyelitis: A comparative histopathological study

Abstract It is largely known that some oral diseases can be diagnosed based upon their clinical manifestation combined with the patient's medical history and generally not depending on examination. This is the case of some bone diseases such as osteoradionecrosis of the jaw (ORNJ), osteomyelitis of the jaw (OMJ), and medication-related osteonecrosis of the jaw (MRONJ). The present study aimed to analyze the histopathological features of these specific bone diseases in order to evaluate similarities and differences. Forty-four bone specimens resected from each bone disease (22 cases of ORNJ, 6 cases of OMJ, and 16 cases of MRONJ) were analyzed by two experienced oral pathologists without prior knowledge of the diagnosis, considering bone tissue condition, inflammation, vascularization, and the presence of microorganisms. In addition, the examiners formulated a diagnostic hypothesis for each specimen. Many histopathological similarities were found among the diseases, especially considering the presence of necrotic bone, inflammation, and microorganisms. Statistically significant differences were detected in empty bone lacunae, which was decreased in ORN (p = 0.042), and considering neutrophil count, which was low in the MRONJ group (p ≤ 0.001). The Kappa coefficient was calculated and agreement was detected based on the histopathological parameters, but not for diagnostic suggestion (p=0.23). In conclusion, histopathological aspects of ORNJ, OMJ, and MRONJ do not permit a conclusive diagnosis, emphasizing the necessity of a detailed clinical report.