Hyperbaric oxygen use in treatment of ORN


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Hyperbaric oxygen use in treatment of ORN

  1. 1. Hyperbaric oxygen therapy use in patients receiving dental implants at risk for osteoradionecrosis Tom Sarna 2/23/07 Chicago’s Midwinter Meeting
  2. 2. Implants <ul><li>Introduced by Branemark </li></ul><ul><li>First titanium implant placed in a human volunteer in 1965. </li></ul><ul><li>Commercially introduced in 1978. </li></ul><ul><li>First intraoral application in 1979. </li></ul><ul><li>Principle of osseointegration makes implants possible. </li></ul>
  3. 3. Osseointegration <ul><li>Def: Direct structural and functional connection between ordered and living bone and surface of load carrying implant. </li></ul><ul><li>An additional clarification that there is direct connection between the bone and the titanium with no fibrous encapsulation. </li></ul><ul><li>Fibrous encapsulated implants will be eventually lost. </li></ul>
  4. 4. 6 factors for osseointegration <ul><li>Material biocompatibility </li></ul><ul><li>lmplant macrostructure </li></ul><ul><li>Implant microstructure </li></ul><ul><li>Surgical technique </li></ul><ul><li>Status of the implant bed </li></ul><ul><li>Loading conditions </li></ul>
  5. 5. Osteoradionecrosis (ORN) <ul><li>Most frequently occurs in the mandible </li></ul><ul><li>A metabolic and tissue homeostatic deficiency due to radiation-induced cellular injury </li></ul><ul><li>Ischemic necrosis of bone – Histopathology shows dominant factor is obliteration of inferior alveolar artery. </li></ul><ul><li>Although microorganisms plays a role in contamination of ORN bone, osteomyelitis differs from ORN. </li></ul>
  6. 6. Histopathology of ORN <ul><li>3 H’s - Hypocellular bone </li></ul><ul><ul><ul><ul><li>Hypovascular tissue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypoxic tissue/bone </li></ul></ul></ul></ul><ul><li>Osteoclast activity reduced </li></ul><ul><li>Osteoblast numbers reduced =collagen production decreased </li></ul><ul><li>Bone marrow suffers vascular injury </li></ul><ul><ul><li>Arteritis of small caliber vessels </li></ul></ul><ul><ul><li>Sclerosis of connective tissue </li></ul></ul><ul><ul><li>Alteration of nutritional supply </li></ul></ul>
  7. 7. Adjunctive Treatment for Irradiated Patients <ul><li>Antibiotics </li></ul><ul><ul><li>Penicillin pre/post surgery </li></ul></ul><ul><ul><li>Tetracycline 100 mg daily prophylaxis </li></ul></ul><ul><li>Saline rinses </li></ul><ul><li>Hyperbaric oxygen use </li></ul>
  8. 8. Hyperbaric oxygen therapy <ul><li>Does not affect necrotic bone </li></ul><ul><li>Target is the viable bone and soft tissue </li></ul><ul><li>Goal is to revascularize radiated tissues and to improve fibroblastic density </li></ul><ul><li>Healing process requires oxygen for: </li></ul><ul><ul><li>Differentiation of fibroblasts </li></ul></ul><ul><ul><li>Synthesis of collagen </li></ul></ul>
  9. 9. Marx protocol <ul><li>20 “dives” before treatment/10 “dives” after treatment </li></ul><ul><li>“Dives” - The slang term for a cycle of pressurization inside the HBOT chamber </li></ul><ul><li>regimen of oxygen at 2.5-2.8 absolute atmosphere pressure (ATA) for 90-120 minutes. </li></ul>
  10. 10. HBO2 Risks <ul><li>Mild problems : claustrophobia (in monoplace chambers), fatigue, and headache. </li></ul><ul><li>More serious complications: myopia (short sightedness) that can last for weeks or months, sinus damage, ruptured middle ear, and lung damage. </li></ul><ul><li>Major complication: oxygen toxicity can result in convulsions, fluid in the lungs, and even respiratory failure. </li></ul>
  11. 11. Hyperbaric oxygen therapy <ul><li>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. </li></ul><ul><li>Promoting angiogenesis in tumor cells is also a risk factor in HBO therapy </li></ul>
  12. 12. HBO induced angiogenesis <ul><li>Marx demostrated a measurable change in angiogenesis after eight sessions </li></ul><ul><li>Plateau at 80% to 85% of nonirradiated tissue level after twenty sessions </li></ul><ul><li>After three years, tissue O2 levels were within 90% of original values suggesting that HBO induced angiogenesis does not regress with time significantly. </li></ul>
  13. 13. Study: Granstrom 1999, Osseointegrated implants in irradiated bone <ul><li>4 groups </li></ul><ul><li>A: irradiated: 32 patients/ 147 implants placed/79 lost (53% failure) </li></ul><ul><li>B: nonirradiated: 26 patients/ 89 implants/12 lost (13.5% failure) </li></ul><ul><li>C: irradiated + HBO use: 20 patients/99 implants/8 lost (8.1% failure) </li></ul><ul><li>D: irradiated failed, retreated after HBO use:10 patients/43 implants/34 lost 1 st (79% failure) / 5 lost 2 nd (11.9% failure) </li></ul>
  14. 14. Study: Granstrom 1999, Osseointegrated implants in irradiated bone analysis <ul><li>No differentation between when implants are placed after irradiation – a good determinate of success rate </li></ul><ul><li>Also, later placement helps explain the great improvement in success rate of Group D (79%/12%) </li></ul>
  15. 15. 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%
  16. 16. Merickse-Stern 1999 <ul><li>Shows a good success rate without hyperbaric oxygen in implant placement in irradiated bone </li></ul>
  17. 17. Weischer 1999 “Ten-Year Experience in Oral Implant Rehabilitation <ul><li>Irradiated patients vs. nonirradiated patients </li></ul><ul><li>Small sample size irradiated patients (17 patients, 73 implants) </li></ul><ul><li>No hyperbaric oxygen control group </li></ul>
  18. 18. Weischer 1999 “Ten-Year Experience in Oral Implant Rehabilitation <ul><li>Encouraging success rate of clinically osseointegrated implants in both irradiated and nonirradiated patients </li></ul><ul><li>75% success rate after 7 years in irradiated patients </li></ul><ul><li>86% success rate after 10 years in nonirradiated patients </li></ul>
  19. 19. Niimi 1998 <ul><li>Implants placed between 2-10 years are more successful </li></ul><ul><li>Longer implants are more successful </li></ul><ul><li>There were no failures of mandibular implants with or without adjunctive HBO therapy </li></ul><ul><li>Higher doses of radiation lead to poorer success rates </li></ul><ul><li>Very little data for maxillary implants </li></ul>
  20. 20. Wagner, 1998 “ Osseointegration of implants in irradiated patient” <ul><li>No hyperbaric oxygen use </li></ul><ul><li>275 implants in 63 irradiated patients </li></ul><ul><li>Osteoradionecrosis: 1.6% </li></ul><ul><li>1 patient out of 62 </li></ul><ul><li>Osseointegration: 97.9% </li></ul><ul><li>269 implants out of 275 </li></ul>
  21. 21. Summary of implant studies in irradiated bone <ul><li>Attraumatic surgery is best determinate of healing without ORN </li></ul><ul><li>Good success rate without hyperbaric oxygen </li></ul><ul><li>Higher success rate when combined with hyperbaric oxygen </li></ul><ul><li>Rarely is osteoradionecrosis caused by implant surgery, studies analyze success rate of osseointegration </li></ul><ul><li>Should wait at least 1.5 years after irradiation to place implants </li></ul>
  22. 22. Hyperbaric oxygen centers in Chicago <ul><li>Arlington Heights Longevity Institute </li></ul><ul><li>Arlington Heights, IL </li></ul><ul><li>Lutheran General Hospital </li></ul><ul><li>Park Ridge, IL </li></ul><ul><li>Midwest Hyperbaric Institute Bolingbrook, IL </li></ul><ul><li>Swedish Covenant Hospital – Wound Care Center </li></ul><ul><li>5145 N. California Chicago, IL </li></ul>