This document summarizes complications that can arise from radiation therapy, including acute and late effects. Acute complications include mucositis, skin reactions, and infection. Late complications discussed include xerostomia, radiation caries, trismus, radiation-induced malignancies, and osteoradionecrosis. Risk factors for osteoradionecrosis include radiation dose, use of brachytherapy, time since radiation, and dental extractions post-radiation. Management of osteoradionecrosis may include the use of hyperbaric oxygen therapy, though its efficacy remains unclear due to limited high-quality studies.
Oral Cancer is an uncontrollable growth of cells which invades the vital structure. It can occur anywhere in the mouth. It occurs due to tobacco use, Areca nut, Alcohol, Poor nutrition, HPV virus, Genetic factors, Chronic trauma.
A red and white patches on lips or gum tongue or Buccal Mucosa having symptoms of pain, hoarseness of voices, loosening of teeth, Biopsy, Endoscopy, Imaging Technique are some way of examination.
Treated by Surgery , Radiation Therapy, Chemotherapy, Brachial Therapy.
Habit Cessation and Maintenance of oral hygiene prevents Cancer.
Call us regarding Oral cancer and its Treatment:-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
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Side effects of radiation in head and neck cancerAnagha pachat
this presentation describes how radiation effects normal structures in head and neck region and about the late and acute toxicities which may occur if the radiation exceeds tolerance dose as per QUANTEC
Oral Cancer is an uncontrollable growth of cells which invades the vital structure. It can occur anywhere in the mouth. It occurs due to tobacco use, Areca nut, Alcohol, Poor nutrition, HPV virus, Genetic factors, Chronic trauma.
A red and white patches on lips or gum tongue or Buccal Mucosa having symptoms of pain, hoarseness of voices, loosening of teeth, Biopsy, Endoscopy, Imaging Technique are some way of examination.
Treated by Surgery , Radiation Therapy, Chemotherapy, Brachial Therapy.
Habit Cessation and Maintenance of oral hygiene prevents Cancer.
Call us regarding Oral cancer and its Treatment:-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
Follow us here:-
• Google+ link: https://goo.gl/vqAmvr
• Facebook link: https://goo.gl/tui98A
• Youtube link: https://goo.gl/mk7jfm
• Linkedin link: https://goo.gl/PrPgpB
• Slideshare link : http://goo.gl/0HY6ep
• Twitter Page : https://goo.gl/tohkcI
• Instagram page : https://goo.gl/OOGVig
Learn more:-
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
Side effects of radiation in head and neck cancerAnagha pachat
this presentation describes how radiation effects normal structures in head and neck region and about the late and acute toxicities which may occur if the radiation exceeds tolerance dose as per QUANTEC
Management of Radiation Toxicity in H & Ndrmadhup1
Management of Radiation Toxicities in head and neck cancer. Radiation is the most important mode of treatment for head and neck cancer patients. It causes both acute and late side effects. Oral mucositis an early or acute reaction which is the limiting factor in all patients. Its management guidelines has been given by MASCC and been updated time to time. Counselling is very important. General oral care and dental prophylaxis is very important before starting the treatment. High end planning in the form of IMRT may help in reducing the OM. Delineation of oral mucosa during RT may help. Use of Glutamine, Honey is also recommended. Benzydamine gargle to be used. Chlorhexidine gargles are not recommended. Proper control of Pain and infection is of para mount importance. Radiation dermatitis is also an acute side effects and its management involves general skin care, washing, topical steroids and some cream based upon aloe vera. Xerostomia is also a late complication which can be addressed by dysphagia optimized IMRT technique which has shown positive results in randomized trial. Symptomatic patient may be asked to use water frequently as well as some artificial saliva preparation in day today life. Dysphagia is another late side effect can be managed by dietary counselling. Other late side effects include Trismus, sub cutaneous fibrosis of neck and late stages lymphedema. It management includes prevention and treatment by pentoxyphylline and vitamin E.
Repeated exercises after radiotherapy is must.
At the End oF this Discussion we will be able to Describe
Which are the Diseases Of the Lips??
Swelling?
Generalized
Localized
Angular Cheilitis?
Lip Fissures?
Allergic Cheilitis?
Actinic cheilitis?
Exfoliative
Perioral Dermatitis?
Lick Eczema?
Cheilocandidiosis
Dr. ShahzaD Hussain
BDS, FCPS(r)
Oral & Maxillofacial Surgery
Nishtar Institute Of Dentistry, Multan
SNDENTALCARE.CO
Osteoradionecrosis is a severe complication arising from head and neck radiotherapy. Mainly affecting the posterior mandible, it often manifests in molars and premolars. Common risk factors include high radiation doses, teeth extractions, and smoking. In the context of treatment, ORN can be categorized into four grades (1-4) based on severity.
Key Points:
Incidence: Occurs in approximately 7.5% of cases, with a median onset time of 8 months post-radiotherapy.
Risk Factors:
Higher incidence with elevated mean radiation doses to the mandible.
Smoking and pre-radiotherapy dental extractions significantly increase the risk.
Treatment Approaches:
Conservative management for early stages.
Surgical interventions include sequestrectomy (Stage 2) and, in severe cases, resection (Stage 3, involving mandibulectomy).
Hyperbaric oxygen therapy may aid in non-healing cases.
Prevention:
Precise dose planning tailored to individual patients crucial for minimizing risks.
Consideration of patient-specific factors, such as smoking and dental history, in treatment planning.
ORN underscores the importance of meticulous treatment planning and individualized approaches to minimize this debilitating complication.
MedActive Oral care products are for people suffering from dry mouth conditions because of chronic medical issues or the taking of multiple medications. We service pharmacy and senior/ LT care facilities. Join the MedActive Team and provide your patients with the most effective products on the market for Dry Mouth.
Gavrilina Olga
National Research Center for Hematology, Moscow, Russian Federation
High-dose chemotherapy with autologous stem cells transplantation in the treatment of patients with diffuse large B-cell lymphoma with bone marrow involvement.
Ольга Александровна БЕРЕЗИКОВА, Главный врач, ГКУЗ КО Кемеровский областной хоспис, Кемерово, РФ
Доклад: "Организация школы "Жизнь без боли""
Olga A. BEEZIKOVA, Chief doctor, Hospice Kemerovo,
Kemerovo, RF
Life without pain
О НЕОБХОДИМОСТИ СТРАТЕГИИ РАЗВИТИЯ ПАЛЛИАТИВНОЙ ПОМОЩИ В РОССИЙСКОЙ ФЕДЕРАЦИИ
Ольга Ивановна УСЕНКО, Член правления Специальной комиссии по паллиативной помощи в странах
Центральной и Восточной Европы, Россия
- - -
ABOUT THE NECESSITY OF STRATEGY DEVELOPMENT OF THE PALLIATIVE CARE IN RUSSIAN FEDERATION
Olga I. USENKO, Member of the Board,
Eastern and Central Europe Palliative Care Task Force
Russia
САМАРСКИЙ ХОСПИС. ИСТОРИЯ И ФАКТЫ.
Ольга Васильевна ОСЕТРОВА, Главный врач, АНО Самарский Хоспис
Ольга Семеновна КОРКУНОВА, Заместитель главного врача, АНО Самара, РФ
- - -
HOSPICE SAMARA. HISTORY & FACTS.
Olga OSETROVA, Сhief doctor,
Olga KORKUNOVA, Deputy chief doctor
Samara Hospice, Samara, RF
ПАЛЛИАТИВНАЯ МЕДИЦИНСКАЯ ПОМОЩЬ В РОССИЙСКОЙ ФЕДЕРАЦИИ.
Георгий Андреевич НОВИКОВ, Д.м.н., Профессор, Председатель Правления Российской Ассоциации паллиативной медицины,
Москва, Российская Федерация
- - -
THE STATE OF HOSPICE & PALLIATIVE CARE IN RUSSIAN FEDERATION.
Prof. Georgiy A. NOVIKOV, Chairman of the Board, Russian Palliative Medicine Association,
Moscow, Russian Federation
CONTEMPORARY PRINCIPLES OF PAIN MANAGEMENT.
Bruce CLEMINSON, Macmillan Palliative Care Education Facilitator, Fellow of the Royal College of General Practitioners & Member, European Association for Palliative Care, Shetland, United Kingdom
- - -
СОВРЕМЕННЫЕ ПРИНЦИПЫ ОБЕЗБОЛИВАНИЯ.
Брюс КЛЕМИНСОН, Координатор образовательных программ по паллиативной помощи центра Мак Миллан, член Королевской коллегии врачей общей практики, Шетландские острова, Великобритания
ОБУЧЕНИЯ РОДСТВЕННИКОВ УХОДУ В ДОМАШНИХ УСЛОВИЯХ. ИНФОРМАЦИОННО-ОБРАЗОВАТЕЛЬНЫЙ РЕСУРС ВЫБИРАЯНАДЕЖДУ.РФ
БЯЛИК Марина Александровна, Президент организации «Инициатива по улучшению паллиативной помощи», Бостон, США
- - -
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Complications from radiation therapy by A. Rapidis
1. The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012
Complications from Radiation
Therapy
Alexander Rapidis
2. Radiation Therapy
General Statements
• Radiation alone or with other treatment
modalities is used in a significant number of
patients with advanced stage oral cancer
• A therapeutic dose of 50-70 Gy is externally
delivered to the tumor
• Usually, increments of 200 cGy/day is
delivered until the accumulated dose is
2012
achieved
5. Mucositis
Symptoms
• Intense pain
• Food and fluid intake decreases
• Speech and swallowing becomes difficult
• Its intensity may require ceasing therapy
2012
6. WHO Oral Mucositis Scale
Severe
Oral Mucositis
Grade
0 1 2 3 4
None Soreness Erythema, Ulcers, Mucositis
+/– ulcers extensive to the extent
erythema erythema that
Patients alimentation is
No can Patients not possible
ulceration swallow cannot
solid diet swallow solid
diet
2012
7. Mucositis
Clinical Characteristics
Grade I Painless ulcers, erythema, or mild
soreness
in the absence of ulcers
2012
8. Mucositis
Clinical Characteristics
Grade II Painful erythema, edema, or ulcers but eating
or swallowing possible
2012
21. Sparing the parotid glands with IMRT
significantly reduces the incidence of
xerostomia and leads to recovery of
saliva secretion and improvements in
associated quality of life, and thus
strongly supports a role for IMRT in
squamous-cell carcinoma of the head
and neck.
2012
www.thelancet.com/oncology Published online January 13, 2011
22. Xerostomia
Treatment
• Lubricants
• Gustatory stimulation
• Drug intervention
• Submandibular gland
relocation
2012
• Daily living “tricks” or
maneuvers
26. Trismus
• More common with high posterior fields of
radiation
– as muscles of mastication are in field
(10%)
• Retention of coronoid process
• Made worse by concomitant chemotherapy
2012
27. Trismus
Pathogenesis
• Direct effects of radiation on muscles and/or TMJ
Clinical Characteristics
• Limited range of motion
Management
• Prevent with stretching exercises
• Prophylactic or therapeutic pentoxifylline, a-
2012
tocopherol
29. Late Complications Following RT
No Event occurs
event above threshold
dose, severity ↑
with dose
Event can occur at any dose
level
Probability, not severity, ↑ with
dose
2012
Increasing RT Dose
30. Late Complications Following RT
Xerostomia
Soft tissue
fibrosis
Osteoradionecros
is
Radiation associated
tumors
2012
Increasing RT Dose
33. Background
• Devastating complication of radiation
therapy that can be more difficult to
treat than original tumor
• Clinical definition:
Devitalized, irradiated bone that is
exposed through overlying mucosa or
2012 skin persisting for > 6 months
34. Osteoradionecrosis is the clinical condition in which irradiated bone
becomes devitalized and exposed through the overlying skin or
mucosa persisting without healing for 3 months.
2012
Marx RA, J Oral Maxillofac Surg 1983
35. Osteoradionecrosis is perhaps the most dreaded late
complication of radiotherapy affecting mandibular bone more
frequently than any other bone in the head and neck.
2012
37. Pathophysiology of Osteoradionecrosis.
Direct radiation effects on normal tissue may be
lethal or sublethal
Lethal damage is caused by
ionization within the desoxyribonucleinic acid
(DNA) preventing cell replication and resulting in
tissue death
2012
Sublethal damage may cause cell mutation
leading to further neoplasia
38. The irradiated mandible, periosteum, and overlying
soft tissue undergo hyperemia, inflammation,
and endarteritis.
These conditions ultimately lead to thrombosis,
cellular death, progressive hypovascularity, and
fibrosis.
2012
40. The incidence of osteoradionecrosis varies considerably between various
studies and is reported to be between 1-40% of patients receiving
radiotherapy in the head and neck area.
Mendenhall WM J Clin Oncol 2004
2012
Reuther et al, Int J Oral Maxillofac Surg 2003
41. 2012
S. Vudiniabola, C. Pirone, J. Williamson, A. N. Goss: Hyperbaric oxygen in the therapeutic
management of osteoradionecrosis of the facial bones. Int. J. Oral Maxillofae. Surg. 2000; 29:
435-438.
43. • Osteoradionecrosis presents as a broad
spectrum of disease severity
• It is rare at radiation therapy doses of less 60 Gy
• It is more common when brachytherapy is used
• The mandible must be in the treatment volume area
• Dental extractions, surgery or trauma usually
proceed its onset
• Secondary infection may be present
2012
44. Factors Affecting the Occurrence of Osteoradionecrosis.
1. Field of irradiation
2012
Thorn JJ et al, J Oral Maxillofac Surg 2000
45. 2. The dose of irradiation
Total doses above 64 Gy resulted in 95% of cases with
osteoradionecrosis of the mandible in a cohort of 80 patients
Thorn JJ et al, J Oral
Maxillofac Surg 2000
Curi MM and Lauria L, J Oral
Maxillofac Surg 1997
2012
46. 3. Time after radiation treatment
Most of the reported cases of osteoradionecrosis of the mandible
occur between 2-5 years after radiation treatment
Thorn JJ et al; J Oral Maxillofac Surg 2000
2012
Fujita M et al, Int J Rad Oncol Biol Phys 1996
47. 4. Variation in treatment fractionations
Conventional fractionation and total dose 67,0-72,0 Gy: ORN 20,1%
Hyperfractionated irradiation and total dose 72,0-78,8 Gy: ORN 6,6%
2012
Studer G et al, Strahlenther Onkol 2004
48. 5. Type of radiation treatment
Brachytherapy is reported to cause the highest rate of osteoradionecrosis of
the mandible. The use of spacers may reduce its occurrence
2012
Miura M et al, Int J Radiation Oncology Biol Phys 1998
49. Intensity Modulated Radiation Therapy (IMRT)
Conformal radiotherapy reduces the dosage to the mandibular bone when
the mandible is not the target of treatment
2012
Claus F et al, Oral Oncology 2002
51. Extractions & Osteonecrosis
Traditional Concepts
• Twice the risk of ORN is seen when selected
teeth are extracted following radiation
therapy
• Pre-radiation extractions associated with a
lower risk of ORN
• Risk of ORN persists for years and reduced
2012
healing capacity may be considered
permanent
52. Tooth extraction and dental disease in irradiated regions have long been
recognized as the major risk factors in the development of
osteoradionecrosis.
Thorn JJ et al, J Oral Maxillofac Surg 2000
2012
Støre G et al, Clin Otolaryngol 2002
53. Nearly 85% of 1,194 irradiated patients followed in the
MSKCC Dental Service from 1998 through 2001 did not
require dental extractions to prevent ORN. Our
retrospective data review indicated that only 11 of 1,194
patients (0.92%) developed ORN, including 4 patients
2012 (2.14%) who had extractions at MSKCC, a much lower
rate than that typically reported in the literature.
54. In conclusion, the present study showed a low
prevalence of ORN related to exodontia: only 2
ORN (0.5%) cases associated with 1.647
exodontia performed before radiotherapy and 1
ORN case (1.7%) in 290 exodontia after
2012
irradiation.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e1-e6
55. Incidence of ORN in the mandible
Angle
12%
Body
Mental 86%
2%
2012
58. There are several classifications for mandibular osteoradionecrosis
and they all stage the disease according to the severity of signs and
symptoms in either Stages, Grades or Scores
2012
59. 2012
RTOG: Radiation Therapy Oncology Group
Jereczek-Fossa BA and Orecchia R, Cancer Treatment Reviews 2002
66. The Role of Hyperbaric Oxygen
HBO treatment involves the delivery of 100% oxygen at high
pressure in special chambers. The pressure of the oxygen inhaled by
the patient is usually 2.4 times more than the atmospheric pressure
and can be as high as 3 times more.
2012
67. Most of the literature indicates that HBO has no impact
on tumor growth - be it stimulatory or inhibitory.
2012
68. However, the general consensus is that HBO
does not offer any significant clinical benefits or
improvement in survival
2012
69. Advocates of HBO therapy support the view that HBO represents the only medical
treatment for osteoradionecrosis. HBO can revert the delayed radiation changes in
tissues by generating steep oxygen gradients between the normal and the
irradiated tissues causing oxygen to diffuse into the affected areas.
2012
70. The Role of Hyperbaric Oxygen
HBO has been used as an adjunctive conservative measure along
with antibiotics and irrigation since the 1960s.
Using Marx’s theory that osteoradionecrosis is a result of hypoxia,
hypocellularity and hypovascularity, HBO seems likely to increase
oxygen supply in hypoxic tissues, stimulating fibroblast proliferation
and angiogenesis.
2012
71. The role of HBO in the
treatment of
osteoradionecrosis.
The Marx protocol
(1982)
2012
Gal TJ et al, Arch Otolaryngol Head Neck Surg 2003
72. The use of HBO in the treatment of osteoradionecrosis despite its widespread
use had been largely theoretical or anecdotal because of the paucity of
controlled trials and the lack of unified assessment of symptom
improvement.
2012
Epstein J et al, Oral Surg 1997
73. The role of HBO in
the treatment of
osteoradionecrosis.
The study by
Annane et al
(2004)
The first randomized,
placebo-controlled,
double-blind study
assessing the
efficacy and safety of
HBO for the
treatment of overt
mandibular
osteoradionecrosis
and included 68
patients.
2012
Annane D et al, J Clin Oncol 2004
74. The trial was terminated prematurely because of the failure to demonstrate
any beneficial effect of HBO over placebo (19% vs. 33% respectively).
They also reported the progression of disease in recovery in the arm of HBO
patients and better recovery rates in the arm of the placebo treated patients.
2012
Annane D et al, J Clin Oncol 2004
75. The study by Annane resulted into strong criticism and
disbelief by several authors quoting that it violated an
ethical principle by exposing the control group to the
potentially serious risk of acute decompression illness; a
risk not present in the treatment group.
Others stated that a major error in Annane’s study was the
fact that the studied group of patients with an
osteoradionecrosis was not well defined.
There were though supporters of the Annane study
presenting evidence that the beneficial results of HBO
2012
treatment are equivocal and the method is time
consuming and expensive.
76. Although the cohort was small it seems that HBO
was of little benefit. HBO is demanding for patients
and has cost implications for the NHS; hence
further clinical outcome data are urgently required
with regard to its role in the management of ORN.
2012
77. HBO therefore remains ineffective as a stand-alone
therapy or even as a reliable adjuvant. Variability
among investigation techniques at various centers
makes it difficult to completely write off HBO as a
potential therapeutic adjuvant.
The debate is still going on.
2012
78. The use and efficacy of HBO prior to tooth extraction
has been debated in the literature.
Those who argue against the use of HBO prior to tooth
extraction state that:
the overall risk of developing ORN with pre-radiation
or postradiation extractions is quite low,
HBO therapy is expensive, and
it is time consuming
2012
79. The use of HBO therapy prior to implant placement has
also been debated. The use of HBO may decrease
morbidity and increase the success of dental implant
therapy. Recent studies have shown an increase in long-
term dental implant failure in patients who did not
receive HBO with implant placement.
2012
85. One of the adverse factors implemented in the
development of ORN is the Radiation Induced
Fibrosis (RIF) and necrosis.
It has been shown that RIF greatly regressed after
antioxidant treatment with the combination of
pentoxifylline, tocopherol and clodronate.
2012
Delanian S et al Head Neck 2005
86. With this treatment applied to 18 patients with advanced ORN,
16 (89%) recovered after a median 6 months of treatment.
The results of this trial raise many questions primarily about the
precise mechanisms of action of the drugs used, which will remain
unanswered until further randomized clinical trials will be conducted.
2012
Delanian S et al Head Neck 2005
87. Selection of Treatment in ORN
Stage I
Superficial Ulceration
Exposed cortical bone
Conservative
management:
Debridement
Meticulous oral hygiene
Antibiotics
2012
88. Stage I: Perform 30 HBO dives (1 dive per day, Monday-Friday) to 2.4
atmospheres for 90 minutes.
Reassess the patient to evaluate decreased bone exposure, granulation
tissue that covers exposed bone, resorption of nonviable bone, and absence
of inflammation.
For patients who respond favorably, continue treatment to a total of 40
dives. For patients who are not responsive, advance to stage II.
2012
89. Selection of Treatment in ORN
Stage II
Exposed medullary bone
+ soft tissue changes
Conservative Surgical
management:
Sequestrectomy
in addition to other
conservative measures
HBO cannot revitalize dead
bone
2012
90. Stage II: Perform transoral sequestrectomy
with primary wound closure followed by
continued HBO to a total of 40 dives.
If wound dehiscence occurs, advance
patients to stage III.
Patients who present with orocutaneous
fistula, pathologic fracture, or resorption to
the inferior border of the mandible advance
2012 to stage III immediately after the initial 30
dives.
91. Selection of Treatment in ORN
Stage III
Sinus/Fistula
Pathologic Fracture
Extensive soft tissue
involvement
Extensive bony loss
2012
93. Stage III: Perform transcutaneous mandibular resection, wound
closure, and mandibular fixation with an external fixator or
2012 maxillomandibular fixation, followed by an additional 10
postoperative HBO dives.
94. The only successful treatment of advanced
(Stage III) mandibular osteoradionecrosis is the
surgical resection of diseased tissues and their
reconstruction with free tissue transfer
2012
95. Conservative measures, such as limited debridement
and HBO therapy, may be effective in preventing the
progression of ORN. However, they fail to eradicate
established ORN, which requires radical surgical
resection followed by functional reconstruction with
2012
well-vascularized tissue.
96. Patients who initially present with advanced disease
(stage II or III) are unlikely to respond to HBO and
conservative therapy. These patients require
extensive debridement leading to large composite
defects.
2012
100. Reconstructive options in the treatment of
severe (Stage III) mandibular osteoradionecrosis
1. The radial forearm osteocutaneous flap
2. The fibula osteocutaneous flap
3. The use of additional flaps
2012
101. 2012
Militsakh ON et al, Otolaryngol-Head and Neck Surg 2005
107. Reconstructive options in the treatment of
severe (Stage III) mandibular osteoradionecrosis
1. The radial forearm osteocutaneous flap
2. The fibula osteocutaneous flap
3. The use of additional flaps
2012
114. Reconstructive options in the treatment of
severe (Stage III) mandibular osteoradionecrosis
1. The radial forearm osteocutaneous flap
2. The fibula osteocutaneous flap
3. The use of additional flaps
2012
116. The rate of post-operative complications during
the surgical treatment of mandibular
osteoradionecrosis is extremely high and when
they occur usually require additional surgery
.
2012
Ang E et al, Br J Plast Surg 2003
Gal TJ et al, Arch Otolaryngol Head Neck Surg 2003
120. Conclusion
• Early ORN can be managed conservatively
• Successful treatment of advanced ORN
depends on resection of all necrotic tissue
• Predictable and prompt primary healing of
surgical defect requires well-vascularized
tissue
• Single-stage composite microvascular
tissue transfer provides best opportunity to
2012
achieve successful outcome
121. The question whether HBO should be a
precedent treatment or should be
administered post-operatively or not at all is
unanswered.
2012
122. Conclusions
• Combined modality treatment for oral cancers is
associated with multiple early and late effects which
impact QOL
• Oral complications are common following radiation for
head and neck cancer
• Irradiation of parotid glands is the main cause of
xerostomia
• IMRT reduces the risk of xerostomia
• Pharmacological approaches such as amifostine may have
a similar effect
• The future challenge is to study interventions to reduce
2012 adverse effects in the oral tissues and improve QOL