3. PRINCIPLES OF MANAGEMENT
1. Evaluation and correction of compromised host defence
2. Gram staining & C&S
3. Routine blood examination
4. Imaging
5. Empherical administration of gram stain guided antibiotics.
6. Removal of loose teeth and sequestra.
7. Administration of culture-guided antibiotic and repeated culture
8. Possible placement of irrigation drains & antibiotic impregnated ac
rylic beads.
9. Sequestrectomy, debridement, decortication, resection and recons
truction as indicated.
10. IMF if continuity defect exists or pathalogical # exists.
11. HBO therapy in refractory cases.
7:41:36 AM 3
4. CONSERVATIVE MANAGEMENT: -
Complete bed rest.
Supportive therapy: nutritional support in the form
of high protein and high caloric diet and adequate
multivitamins.
Hydration orally or through administration of i.v. fl
uids.
Control of pain – analgesics
Sedation may be employed for keeping patient comfor
table and allow to sleep.
Blood transfusion – in case RBCs and Hb is low.
I.v. antimicrobial agents – Pencillin the drug of choice
(Vibhagol 1993).
7:41:36 AM 4
5. ANTIBIOTIC THERAPY
ANTIBIOTIC REGIMENS OF OSTEOMYELITIS: -
Regimen I: - 1st choice
As empirical therapy
Aqueous pencillin (crystalline pencillin/ pencillin V) =- 2
million units i.v. every 4 hrly.
Oxacillin =- 1gm I.v. every 4 hrly
When patient has been asymptomatic for 48 to 72 hrs =-
Pencillin V orally 500mg every 4 hrly with Cloxacillin 25
0 mg every 4 hrly for 2-4 weeks.
Regimen II: -
Based on culture and sensitivity results Pencillinase resistant Pencillins, such as Ox
acillin, Cloxacillin, Dicloxacillin or Flucloxacillin.
In case of allergy to Pencillin, the antibiotics preferred in order of preference.
7:41:36 AM 5
6. II choice: - Clindamycin – 300-600mg orally 6 hrly.
It is effective against Pencillinase producing – Staphylococci
Streptococci
Bacteroides (anaerobic
bacteria)
It is used because of its ability to diffuse widely in bone. Not recomme
nded as 1st choice as it is bacteroistatic.
III choice: - Cephalosporins
Cepazelin – 500mg 8 hrly (or)
Cephalexin – 500mg 6 hrly
Effective against most cocci.
Not recommended as 1st choice because they are
Moderately effective against anaerobes.
Because of broad spectrum coverage which increase antibiotic
complications (bacterial resistance and superinfection)
7:41:36 AM 6
7. IV choice: -
Erythromycin 6 hrly i.v. then 500mg 6 hrly orally.
Not used as 1st choice because they are bacteroistatic and rapidly devel
op resistant strains.
Specific infective forms of osteomyelitis include TB, syphilis, and actin
omycosis. Management is same as chronic osteomyelitis and additional t
heir respective appropriate medications have to be instituted.
TB may require therapy for upto 1 yr.
Actinomycosis may require for 2 to 3 months.
Successful antibiotic therapy is indicated by the cessation of pain, swell
ing and discharge with obvious wound healing. Antibiotic therapy should
be continued for a further 2-4 weeks after the patient becomes asymp
tomatic. Antibiotic therapy should be accompanied by adequate fluid re
placement
7:41:36 AM 7
8. Hyperbaric oxygen therapy – HBO
Inhalation of 100% humidified O2 under pressure > 1 a
tm absolute pressure.
Patient is placed in chamber. O2 is given by mask or by
hood. Each dive is 90 mins in length.
Treatment is given 5 days per week for 30, 60 dives.
For more dives in monoplace chamber at 2.4 ATA pres
sure given in monoplace a week.
HBO therapy over the last several decades emerged a
s
A patent alternative to surgical reperfusion.
As an adjunctive enhancement to host-immune res
ponse.
Its use has been increased in treatment of osteomyeli
tis and osteoradionecrosis.
7:41:36 AM 8
10. Surgical management
It is an adjunct to medical treatment
In acute stage, surgery should be limited to removal of severely
loose teeth, bone fragments , I & D of fluctuant areas
If necessary saucerization , decortication or reconstruction is d
one.
Superficial abscesses are managed by initial drainage & debride
ment under LA & sedation
Deeply located / extensive abscesses may require treatment und
er GA
Heat should be avoided in such cases because it may encourage e
xtension of infection through bone
7:41:36 AM 10
11. SURGICAL MANAGEMENT
Sequestrectomy :Removal of sequestrum.
Saucerization: excision of the margins of the necroti
c bone over a focus of osteomyelitis, which allows visu
alization of the sequestra and excision of the affecte
d bone. It should be performed intra-orally when ever
possible. The defect is packed open to allow exfoliatio
n of unrecognized sequestra.
Decortication: removal of chronically infected lateral
or inferior cortical plates of bone 1-2cms beyond the
area of the involved bone. This was first described in
1917 and further by Mowlem in 1945 and by Hjorting-
Hansen in 1970.
7:41:36 AM 11
12. SAUCERIZATION
Outline of bone removal,after reflection of the mucosa, loose
teeth are removed and the superior aspect of the buccal plate is
excised along the extent of the involved area.
A medicated pack is placed within the saucer slightly overfilli
ng the defect. The mucosa is trimmed and several sutures are
tied over the pack to maintain it in place.
Following healing. The bone remodels and is covered by norm
al mucosa
7:41:36 AM 12
13. SURGICAL MANAGEMENT
Decortication: It is based on the presumption that in
volved cortical bone is avascular and they harbor micr
oorganisms while an abscess exits within the medullar
y cavity where antibiotics cannot reach.
Decortication may be used as the initial treatment op
tion for primary and secondary osteomyelitis or more
commonly in situations where the initial conservative r
egimens have failed.
Although originally performed extra-orally, decortica
tion is now done as an intra-oral procedure.
7:41:36 AM 13
14. DECORTICATION
The lateral cortical pl
ate and a portion of th
e inferior cortical plat
e are removed to a dis
tance of 1 to 2 cm be
yond the involved are
a.
Usually bone that sup
ports teeth are involv
ed and that necessiate
s tooth removal.
Vascularised muscle
flap is shown approx
imating the bony sur
face when the teeth a
re retained.
And when the teeth are
removed
7:41:36 AM 14
15. SURGICAL MANAGEMENT
The steps involved are:
1. Raising the buccal flap with reflection of the mucoperiosteum upt
o the inferior border.
2. Removal of teeth in the involved area along with removal of the l
ateral cortical plate and the inferior border with the chisels pre
ferably in one piece. Bone must be cut back to the uninvolved are
as as evidenced by bleeding points in bone margins.
3.The bony bed is thoroughly debrided and the flap is closed primar
ily and the dead space is eliminated by applying pressure bandag
e. Irrigation tubes may be placed
7:41:36 AM 15
16. Closed wound irrigation and suction.
After debridement there might be some chronically i
nfected residual bone left over for which placement o
f tubes against the bone may be desirable to allow dr
ainage of pus and serum and to provide a route throug
h which antibiotics may be installed in high concentra
tions locally.
The technique involves placement of small tubes into
the bony bed of the saucerized or decorticated woun
d and watertight closure of the wound is achieved.
One or two small pediatric nasogastric feeding tubes
or french catheters or polyethylene irrigation tubes o
f 3-4mm in diameter with perforated holes may be us
ed.
7:41:36 AM 16
17. The tubes are flushed with saline and the irrigating solution is in
troduced through one tube while the other tube is connected to
the low-pressure suction. Various irrigation solution like 1% Neo
mycin with 0.1% Polymycin B may be used.
Cultures are made from the specimen collected and irrigation is
continued for 1 week after three successive cultures are negativ
e. The systemic administration of the antibiotics should be conti
nued through the period of irrigation.
7:41:36 AM 17
20. RESECTION AND IMMEDIATE R
ECONSTRUCTION:
Osteotomy is performed mostly through intra-oral ap
proach. The wound is extensively and repeatedly irrig
ated.
A block of cancellous iliac crest bone or cancellous
marrow is the most desirable graft material. Stabilizat
ion may be achieved by vitalium or titanium mesh.
Immediate reconstruction offers the obvious advantag
e of shortening the period of illness and speeding reha
bilitation
7:41:36 AM 20
21. TYPES OF OSTEOMYELITIS
1. INFANTILE OSTEOMYELITIS
2. CHRONIC RECURRANT MULTIFOCAL OSTEOMYELITI
S IN CHILDREN
3. PROLIFERATIVE PERIOSTITIS (GARRE’S SCLEROSING OS
TEOMYELITIS)
4. CHRONIC SCLEROSING OSTEOMYELITIS
A. CH.DIFFUSE SCLEROSING OM
B. FLORRID OSSEOUS DYSPLASIA
5. CONDENSING OSTEITIS
6. ACTINOMYCOTIC OSTEOMYELITIS
7:41:36 AM 21
22. INFANTILE OSTEOMYELITIS
Not a common disease. Seen often in individuals a fe
w weeks after birth and usually involves maxilla.
Occurs via hematogenous route/ perinatal trauma of t
he oral mucosa from the obstetrician’s finger or the m
ucosa suction bulb used to clear the airway immediate
ly after birth.
Infections involving the maxillary sinus and infected
human or artificial nipples have also been implicated
as sources of infant infection
7:41:36 AM 22
23. INFANTILE OSTEOMYELITIS
Clinically the patient presents with a facial cellulitis centered
about the orbit. Irritability and malaise precede frank celluliti
s, which are followed by hyperpyrexia, anorexia and dehydra
tion. Convulsions and vomiting may occur.
Intra-orally, the maxilla on the affected side is swollen bot
h bucally and palatally, especially in the molar region. Fluctua
nce is often present and fistulas may exist in the alveolar muco
sa.
During the early acute phase, little radiographic changes are no
ted and leucocytosis is generally present.
The antibiotic treatment is started after appropriate sample
s have been taken for culture and sensitivity.
7:41:36 AM 23
24. INFANTILE OSTEOMYELITIS
Staphylococcus aureus is usually the offending organ
ism in majority of the cases. Cloxacillin 200mg/kg IV
should be given in divided doses until the child is clin
ically well, has no fever and the local signs has decrea
sed.
Flucloxacillin 100mg/kg orally can be given. In Strep
tococcal or Pneumococcal infections Benzyl penicilli
n can be given.
For penicillin-hypersensitivity Cephalosporins or Eryt
hromycin or Fusidic acid may be given. Ampicillin is
effective against Hemophilus influenza infection.
7:41:36 AM 24
25. INFANTILE OSTEOMYELITIS
Drainage may be established by the simplest of intra-
oral incisions over the area of maximum fluctuations.
Sequestrectomy should be delayed until the inflamma
tion has subsided and must be as conservative as poss
ible.
Adequate fluid intake and nutrition are crucial an
d are maintained by a fine nasogastric tube through w
hich the antibiotic may also be administered, once the
acute stage is controlled.
7:41:36 AM 25
26. NON SUPPURATIVE OSTEOMYE
LITIS
CHRONIC SCLEROSING OSTEOMYELI
TIS- (Focal & Diffuse)
This is also called :
Sclerosing osteitis,
Multiple enostosis,
Local bone sclerosis,
Ossifying osteomyelitis,
Sclerosing cementoma,
Giantiform cementoma and
Sclerotic cemental masses of jaws.
7:41:36 AM 26
27. Chronic focal sclerosing osteomyelitis
Is an unusual reaction of bone to infection, occurring
in instances of extremely high tissue resistance or in c
ases of a low grade infection.
This form of osteomyelitis arises most commonly
in young persons below 20yrs. The tooth most comm
only involved is first molar, which presents as a large
carious lesion.
There may be no signs or symptoms of the disease ot
her than mild pain associated with an infected pulp.
7:41:36 AM 27
29. OSTEORADIONECROSIS
History:
In 1922, Regaud published the first report abou
t osteoradionecrosis (ORN) of the jaws after ra
diotherapy
During the past 80 years, this condition has pe
rsisted as a consequence of radiotherapy for he
ad and neck cancer in an appreciable minority
of patients.
7:41:36 AM 29
30. Terms Used To Describe Osteoradionecrosis
Radiation osteitis
Radio-osteonecrosis
Radiation osteomyelitis
Osteomyelitis of irradiated bone
Osteonecrosis
Radio-osteomyelitis
Septic osteoradionecrosis
Post-radiotherapy osteonecrosis
7:41:36 AM 30
31. Definitions of osteoradionecrosis
Beumer - When bone in the radiation field was exposed for at least 2 mont
hs in the absence of local neoplastic disease.
Marx - An area greater than 1 cm of exposed bone in a field of irradiation t
hat had failed to show any evidence of healing for at least 6 months.
Hutchinson - An area of exposed bone (mandible) present for longer than
2 months in a previously irradiated field, in the absence of recurrent tumour
.
Epstein - An ulceration of the mucous membrane with exposure of necrotic
bone.
Harris - Irradiated bone becomes devitalised and exposed through the over
lying skin or mucosa, persisting without healing for 3 months in the absenc
e of tumour recurrence.
7:41:36 AM 31
32. OSTEORADIONECROSIS
DEFINITION:
• The classic definition given for osteoradionecrosis wa
s osteomyelitis secondary to radiation with sequelae o
f radiation trauma and infection.
•It was redefined by Marx in 1983 as the concept of 3 H’s
–
Osteoradionecrosis is defined as a chronic non healing w
ound caused by Hypoxia, Hypocellularity and Hypovascul
arity of irradiated tissue.
7:41:36 AM 32
33. ETIOLOGY
1. High dose radiation therapy > 5000 rads (50Gy)
2. 2/3rd occurs in response to surgical trauma. Tooth extractio
n or poor oral hygeine
3. 1/3rd occurs spontaneously with soft tissue breakdown over
non vital bone.
7:41:36 AM 33
34. Risk factors for the development of osteo
radionecrosis
• Size and site of the tumour,
• Dose of radiation and type of mandibular
Resection
• Injury, or dental extractions
• Infection
• Immune deficiencies and malnutrition.
7:41:36 AM 34
36. OSTEORADIONECROSIS
CLINICAL FEATURES
Site affected
The mandible >maxilla
• Because most oral tumors are perimandibular.
• The absence of dense cortical plates
• The presence of a more extensive vascular network in
the maxilla
7:41:36 AM 36
37. OSTEORADIONECROSIS
Pain,
Paresthesia
Trismus,
Fetid breath,
Elevated temperature.
Exposed bone with a gray to yellowish color
Intra-and extra-oral fistulae.
Pathologic fractures
7:41:36 AM 37
38. OSTEORADIONECROSIS
HISTOLOGICAL FEATURES
Terminal endarteritis/endothelial death
Hyalinization and thrombosis of vessels
Periosteum becomes fibrotic
Osteoblasts/cytes become necrotic
Fibrosis of marrow spaces
Mucosa becomes fibrotic with decreased level of vasc
ularity/cellularity
7:41:36 AM 38
39. OSTEORADIONECROSIS
RADIOGRAPHIC FEATURES
Presents like chronic oseteomyelitis
Diffuse sclerotic (radioopaque) appearance
Scattered radiolucencies
Moth eaten appearance
DIAGNOSIS
Xerostomia
Foul odor
Exposed bone
Severe pain
Discharging fistula
Mucosal defect
Cutaneous defect7:41:36 AM 39
41. OSTEORADIONECROSIS
MANAGEMENT
SURGICAL AND NON-SURGICAL
Initial treatment is directed at controlling infectio
n, if present. Ambulatory care is appropriate except in
patients who have toxic symptoms and are dehydrated
; in such patients, hospitalization is recommended to
permit supervised administration of parenteral antibio
tics and fluids.
Penicillin is the antibiotic of choice and can be given
orally at a dose of 500 mg four times daily. Erythrom
ycin, 500 mg four times daily, may be used in penicill
in-allergic patients.7:41:36 AM 41
42. OSTEORADIONECROSIS
Gentle irrigation of the soft tissue margins is useful in
removing debris and reducing inflammation.
If discrete abscesses or cutaneous fistulae are present,
aerobic and anaerobic cultures should be obtained for
sensitivity testing.
Supportive treatment with fluids and a liquid or semi-
liquid diet high in protein and vitamins is desirable. Ir
rigation of exposed bone is performed.
Pain may be controlled with narcotic analgesics, bupi
vacaine (Marcaine) or alcohol nerve blocks, nerve av
ulsion, or rhizotomy.
7:41:36 AM 42
43. Hyperbaric oxygen therapy – HBO
Inhalation of 100% humidified O2 under pressure >
1 atm absolute pressure.
Patient is placed in chamber. O2 is given by mask or
by hood. Each dive is 90 mins in length.
Treatment is given 5 days per week for 30, 60 dives.
For more dives in monoplace chamber at 2.4 ATA p
ressure given in monoplace a week.
HBO therapy over the last several decades emerged
as
A patent alternative to surgical reperfusion.
As an adjunctive enhancement to host-immune r
esponse.
Its use has been increased in treatment of osteomyeli
tis and osteoradionecrosis.
7:41:36 AM 43
44. OSTEORADIONECROSIS
Hyperbaric oxygen therapy
Expressed in DIVES
1 Dive = 90 minutes at 2.4 atmospheres
Tissue oxygen tensions rise to 150-250mm Hg
This elevation quickly returns to hypoxic levels (10 – 15mm Hg)
The intermittent rise in oxygen levels is adequate to stimulate fibroblast
ollagen production
Inturn, the response to collagen formation is vascular proliferation and n
ocellularity of the wound
Irradiated tissue ultimately now has the oxygen supply to keep up with w
ound demand.
7:41:36 AM 44
45. OSTEORADIONECROSIS
Combination therapy:
Even with the enhance of hyperbaric oxygen most ost
eoradionecrosis won’t resolve without surgical debrid
ement due to the following:
Tissues vary in degree of hypocellularity, hypovascul
arity and hypoxia.
Elevated oxygen levels are not maintained
Hyperbaric oxygen cannot revive dead bone
7:41:36 AM 45
46. Hyperbaric oxygen therapy
Breathing 100% oxygen
through a face mask / hood
in a monoplace or a large chamber
at 2.4 atm pressure for 90 min sessions or “div
es”
For 5 days a week totalling 30 or more session
s
7:41:36 AM 46
47. Mechanism of action
Increases arterial & venous oxygen tension
Oxygen under increased tension enhances heal
ing by a direct bacteriostatic effect on microor
ganisms
Neoangiogenesis , fibroblastic proliferation, &
collagen synthesis occurs
7:41:36 AM 47
48. Action: -
Enhancement of lysosomal degradation potential of PMNL and
O2 radicals, which are major components of catabolic enzymes
of macrophage lysosome. Formation of these enzymes is decre
ase in hypoxic environment as in osteomyelitis.
Free radicals of O2 are toxic to many pathogenic anaerobes (bacteriocidal).
Many exotoxins liberated by microorganisms are rendered iner
t by exposure to elevated partial pressure of O2.
Tissue hypoxia is intermittently reversed by HBO therapy mim
icking tissue level during wound healing.
Positive enhancement of neoangiogenesis in the aerobic portio
n of proliferative phase of wound healing.
7:41:36 AM 48
49. Results:
Increase vascular supply.
Increase O2 perfusion to ischaemic areas of infection.
Bacteriocidal or bacteriostatic actions of increase O2 levels.
Enhanced phagocytic ability of leucocytes, stimulate fibroblast growth, increase col
lagen formation, promote growth of new capillaries and osteogenesis.
COMPLICATIONS
Rare, however, primarily associated with barometric pressure changes or oxygen to
xicity
Middle ear dysfunction – Tympanic membrane rupture, hemorrhage, otitis media
Oxygen toxicity – may cause seizures, pulmonary alveolar collapse and edema
Decompression sickness – formation of air bubble outside/inside cardio vascular sy
stem.
MANAGEMENT OF CHRONIC SUPPURATIVE OSTEOMYELITIS
1. Closed wound irrigation- suction
2. Antibiotic impregnated beads
7:41:36 AM 49
51. Stage 1
30x (100% O2 for 90 min at 2.4 A
TA)
Examine exposed bone
10x (100% O2 for 90 min at 2.4
ATA)
(stage 1 responder)
Stage II
Surgery(maintain inferior border of
mandible)
10x (100% O2 for 90 min at 2.4 A
TA)
Stage III
Exicision of nonviable bone
Fixation of mandibular segments
10x (100% O2 for 90 min at 2.4 A
TA)
Reconstruction after 3 months
No further HBO required
Healing without expos
ed bone
(Stage II responder)
Cutaneous fistula
Pathological #
Resorption of inferior bo
rder of mandible
No Response
Response
Response
No Response
Marx University of Miami Protocol
7:41:36 AM 51
52. OSTEORADIONECROSIS
CONTRAINDICATIONS TO HBOT
Pneumothorax – absolute contraindications in patients with a
history of asthma, COPD, emphysema are at risk for tension p
neumothorax. Chest X-ray before hyperbaric oxygen therapy i
s mandatory.
Optic neuritis
Acute viral infection
Upper respiratory infection – hyperbaric oxygen should be d
elayed until infection subsides – congestion makes pressure eq
uilibrium of sinuses and middle ear difficult.
Congenital spherocytosis – condition where there are abnorm
al proteins that cause loss of RBC membrane following hemol
ysis of cells (glucose deprivation) – hyperbaric oxygen exacer
bates hemolysis in these patients.
Active tumour cells – oxygen would cause increased prolifera
tion of any present/active tumor cells.
7:41:36 AM 52
53. PREVENTION
PRE-IRRADIATION DENTAL CARE
All nonrestorable teeth in the direct beam of radiation a
nd teeth with significant periodontal disease and should be e
xtracted before radiation therapy begins.
In patients with poor oral health and poor motivation to mai
ntain oral hygiene, complete extractions are recommended.
Judicious alveoloplasty should be performed to permit a pri
mary mucoperiosteal closure. All sharp bone margins shoul
d be smoothed, because irradiated bone does not spontaneou
sly remodel.
Radiation therapy should be delayed 10 to 14 days to allow i
nitial healing. The need for pre-irradiation antiobiotic cover
age in conjunction with extractions is controversial.
7:41:36 AM 53
54. OSTEORADIONECROSIS
All remaining teeth should be restored and periodontal th
erapy completed within this 2-week interval.
Complete instructions and an opportunity to practice ora
l hygiene should be provided.
A custom tray should be provided for application of 0.4
per cent stannous fluoride gel, or 1 percent acidulated flu
orophosphate gel.
After flossing, fluoride treatment should be performed f
or 15 minutes twice a day for 2 weeks, followed by once
daily
7:41:36 AM 54
55. OSTEORADIONECROSIS
Post-Irradiation Dental Care
Dentures should not be used in the irradiated ar
ch for 1 year after therapy.
Subsequently, patients must recognize the nee
d for adjustment at the first sign of irritation.
If natural teeth are present, the oral hygiene an
d fluoride therapy recommended previously sh
ould be followed.
7:41:36 AM 55
56. OSTEORADIONECROSIS
A saliva substitute may be used to lubricate the mouth
to replace diminished flow from irradiated mucous an
d salivary glands.
A solution known as VA-Oralube was used containi
ng minerals and fluoride. It is intended to facilitate re
hardening of tooth surfaces and to minimize xerostom
ia-induced soft tissue disorders.
When residual salivary gland function is present, pilo
carpine may be useful to stimulate salivary flow.
7:41:36 AM 56
57. OSTEORADIONECROSIS
If post-irradiation pulpitis develops and the inv
olved tooth is restorable, endodontic therapy s
hould be undertaken.
Caution must be exercised not to introduce org
anisms beyond the apex by instrumentation.
Treatment should be performed in conjunction
with administration of a prophylactic antibiotic
.
7:41:36 AM 57
58. OSTEORADIONECROSIS
Necessary extractions should be limited to one to two teeth per
appointment.
Removal of teeth should be performed as atraumatically as pos
sible, with trimming only of sharp bone margins and without a
ttempting to raise extensive flaps or obtain a linear closure.
One million units of aqueous penicilllin is given intravenously
15 minutes before surgery, followed by oral doses of penicillin
V, 500 mg four times a day for 10 days; the initial oral dose is
given 1 hour after the parenteral dose.
Alternately, 1 g of penicillin V may be given orally 1 hour bef
ore the procedure, followed by the previously mentioned posts
urgical regimen.
In patients allergic to penicillin, 1 g of erythromycin 1 hour be
fore surgery and 500 mg four times per day for 10 days are ad
vised
7:41:36 AM 58
59. New protocols for prevention and tre
atment of osteoradionecrosis
Previously, patients who required multiple dental ext
ractions or extensive surgical extractions, or both, mi
ght have been given HBO before and after operation.
Instead, all patients having dental extractions could b
e given eight weeks of pentoxifylline 400 mg twice d
aily with tocopherol 1000 IU, starting a week before t
he procedure.
If ORN developed then they could be continued for a
further 6 months with clodronate prescribed after 3
months if there has been no appreciable response.
7:41:36 AM 59
60. New protocols for prevention and tre
atment of osteoradionecrosis
Patients with established ORN follow this regimen fo
r 6 months; those who do not respond after 3 months
are given clodronate.
Patients who would be excluded are those with pathol
ogical fractures, or in whom pathological fracture see
m likely such as when free vascularised composite tis
sue transfer is planned in the short term. Patients who
would have been given HBO before and after curettag
e or sequestrectomy should be given pentoxifylline an
d tocopherol.
7:41:36 AM 60
61. BIBILIOGRAPHY
Bone & joint infections – Martin Dunitz
Bone in clinical orthopedics –G.Sumner smith
orthopedic infections – Turek’s
Oral & maxillofacial infections –Topazian
British journal of omfs – june 2008
IOWA orthopedic journal
7:41:36 AM 61
