Hyperbaric oxygen use in treatment of ORN
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Hyperbaric oxygen use in treatment of ORN

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Hyperbaric oxygen use in treatment of ORN Hyperbaric oxygen use in treatment of ORN Presentation Transcript

  • Hyperbaric oxygen therapy use in patients receiving dental implants at risk for osteoradionecrosis Tom Sarna 2/23/07 Chicago’s Midwinter Meeting
  • Implants
    • Introduced by Branemark
    • First titanium implant placed in a human volunteer in 1965.
    • Commercially introduced in 1978.
    • First intraoral application in 1979.
    • Principle of osseointegration makes implants possible.
  • Osseointegration
    • Def: Direct structural and functional connection between ordered and living bone and surface of load carrying implant.
    • An additional clarification that there is direct connection between the bone and the titanium with no fibrous encapsulation.
    • Fibrous encapsulated implants will be eventually lost.
  • 6 factors for osseointegration
    • Material biocompatibility
    • lmplant macrostructure
    • Implant microstructure
    • Surgical technique
    • Status of the implant bed
    • Loading conditions
  • Osteoradionecrosis (ORN)
    • Most frequently occurs in the mandible
    • A metabolic and tissue homeostatic deficiency due to radiation-induced cellular injury
    • Ischemic necrosis of bone – Histopathology shows dominant factor is obliteration of inferior alveolar artery.
    • Although microorganisms plays a role in contamination of ORN bone, osteomyelitis differs from ORN.
  • Histopathology of ORN
    • 3 H’s - Hypocellular bone
          • Hypovascular tissue
          • Hypoxic tissue/bone
    • Osteoclast activity reduced
    • Osteoblast numbers reduced =collagen production decreased
    • Bone marrow suffers vascular injury
      • Arteritis of small caliber vessels
      • Sclerosis of connective tissue
      • Alteration of nutritional supply
  • Adjunctive Treatment for Irradiated Patients
    • Antibiotics
      • Penicillin pre/post surgery
      • Tetracycline 100 mg daily prophylaxis
    • Saline rinses
    • Hyperbaric oxygen use
  • Hyperbaric oxygen therapy
    • Does not affect necrotic bone
    • Target is the viable bone and soft tissue
    • Goal is to revascularize radiated tissues and to improve fibroblastic density
    • Healing process requires oxygen for:
      • Differentiation of fibroblasts
      • Synthesis of collagen
  • Marx protocol
    • 20 “dives” before treatment/10 “dives” after treatment
    • “Dives” - The slang term for a cycle of pressurization inside the HBOT chamber
    • regimen of oxygen at 2.5-2.8 absolute atmosphere pressure (ATA) for 90-120 minutes.
  • HBO2 Risks
    • Mild problems : claustrophobia (in monoplace chambers), fatigue, and headache.
    • More serious complications: myopia (short sightedness) that can last for weeks or months, sinus damage, ruptured middle ear, and lung damage.
    • Major complication: oxygen toxicity can result in convulsions, fluid in the lungs, and even respiratory failure.
  • Hyperbaric oxygen therapy
    • The only absolute contraindication to hyperbaric oxygen therapy is untreated pneumothorax. Relative complications include grand mal seizure, fever, the inability to clear the ears or sinuses.
    • Promoting angiogenesis in tumor cells is also a risk factor in HBO therapy
  • HBO induced angiogenesis
    • Marx demostrated a measurable change in angiogenesis after eight sessions
    • Plateau at 80% to 85% of nonirradiated tissue level after twenty sessions
    • After three years, tissue O2 levels were within 90% of original values suggesting that HBO induced angiogenesis does not regress with time significantly.
  • Study: Granstrom 1999, Osseointegrated implants in irradiated bone
    • 4 groups
    • A: irradiated: 32 patients/ 147 implants placed/79 lost (53% failure)
    • B: nonirradiated: 26 patients/ 89 implants/12 lost (13.5% failure)
    • C: irradiated + HBO use: 20 patients/99 implants/8 lost (8.1% failure)
    • D: irradiated failed, retreated after HBO use:10 patients/43 implants/34 lost 1 st (79% failure) / 5 lost 2 nd (11.9% failure)
  • Study: Granstrom 1999, Osseointegrated implants in irradiated bone analysis
    • No differentation between when implants are placed after irradiation – a good determinate of success rate
    • Also, later placement helps explain the great improvement in success rate of Group D (79%/12%)
  • Merickse-Stern 1999 25 patients – 53 implants after irradiation without hyperbaric oxygen 2 y survival 93.9 % 3 y survival 90.5% 5 y survival 90.5%
  • Merickse-Stern 1999
    • Shows a good success rate without hyperbaric oxygen in implant placement in irradiated bone
  • Weischer 1999 “Ten-Year Experience in Oral Implant Rehabilitation
    • Irradiated patients vs. nonirradiated patients
    • Small sample size irradiated patients (17 patients, 73 implants)
    • No hyperbaric oxygen control group
  • Weischer 1999 “Ten-Year Experience in Oral Implant Rehabilitation
    • Encouraging success rate of clinically osseointegrated implants in both irradiated and nonirradiated patients
    • 75% success rate after 7 years in irradiated patients
    • 86% success rate after 10 years in nonirradiated patients
  • Niimi 1998
    • Implants placed between 2-10 years are more successful
    • Longer implants are more successful
    • There were no failures of mandibular implants with or without adjunctive HBO therapy
    • Higher doses of radiation lead to poorer success rates
    • Very little data for maxillary implants
  • Wagner, 1998 “ Osseointegration of implants in irradiated patient”
    • No hyperbaric oxygen use
    • 275 implants in 63 irradiated patients
    • Osteoradionecrosis: 1.6%
    • 1 patient out of 62
    • Osseointegration: 97.9%
    • 269 implants out of 275
  • Summary of implant studies in irradiated bone
    • Attraumatic surgery is best determinate of healing without ORN
    • Good success rate without hyperbaric oxygen
    • Higher success rate when combined with hyperbaric oxygen
    • Rarely is osteoradionecrosis caused by implant surgery, studies analyze success rate of osseointegration
    • Should wait at least 1.5 years after irradiation to place implants
  • Hyperbaric oxygen centers in Chicago
    • Arlington Heights Longevity Institute
    • Arlington Heights, IL
    • Lutheran General Hospital
    • Park Ridge, IL
    • Midwest Hyperbaric Institute Bolingbrook, IL
    • Swedish Covenant Hospital – Wound Care Center
    • 5145 N. California Chicago, IL