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Osteoradionecrosis (ORN)

What is osteoradionecrosis (ORN)?

ORN stands for osteoradionecrosis.  It is seen in patients who have a history of radiation treatment (usually for the treatment of certain head and neck cancers).  This condition results in impaired wound healing and death (necrosis) of the jaw bone usually after a dental extraction.  In susceptible patients (see below), a dental extraction (or other surgical procedure) can cause problems with healing resulting in exposed jaw bone within the mouth and possibly infection.  While ORN is a very rare disorder, it is one that is important to understand due to its potentially severe complications should it develop.


What are the symptoms of osteoradionecrosis (ORN)?

ORN results in exposed jaw bone in your mouth i.e. failure of the gum tissue to cover over your jaw bone after an extraction.  This happens because the bone in the area undergoes necrosis (death) and cannot support gum tissue over it.  Occasionally, the necrotic (dead) bone can become infected resulting in swelling, redness, pain, and drainage of pus.


What specifically places me at risk for osteoradionecrosis (ORN)?

A history of radiation to the jaw bones over a certain dose (50 grays) places you at increased risk for osteoradionecrosis.  If you were treated for head and neck cancer with radiation, it is likely that you are at risk for ORN.

How does radiation cause ostoradionecrosis (ORN)?

Radiation causes damage to tissues.  Specifically in the jaw bones, radiation can decrease blood supply and decrease the ability of the bone to heal itself after a dental extraction or implant.  This can result in bone necrosis (death) after a dental extraction.


What is my risk of osteoradionecrosis (ORN) if I have an oral surgical procedure?

According to most studies, the chances of developing ORN in radiated patients (>50 gray) after dental extraction or dental implant placement is approximately 7%.  Therefore, even if you have a history of radiation to the head and neck, your risk of developing ORN is relatively low, but the disease can be potentially devastating should it occur.  


Can I have a dental implant if I have a history of radiation to the head and neck?

In general, patients who have had a higher dose of radiation (> 50 gray) are not good candidates for dental implant placement due to the risk of ORN.


What can be done to help prevent osteoradionecrosis (ORN) if I need extractions?

If you need dental extractions and have a history of radiation to the areas, there are some things that may be done which could possibly decrease the risk of ORN.  It is worth noting that no therapy has ever been definitively proven to reduce the risk of ORN.  In other words, it is unlikely that any therapy currently available is able to significantly reduce your risk of ORN.  


Despite lack of clear scientific evidence, there are essentially 2 options patients have that might reduce the risk for ORN.  The first involves taking a series of medications which fight infection and improve blood flow prior to and after the extractions.  The second involves hyperbaric oxygen therapy (HBOT). See below for information on HBOT.


What is hyperbaric oxygen therapy (HBOT) and how does it work?

HBOT therapy involves the patient being exposed to increased oxygen levels for an extended period of time in the hopes that the increased oxygen in their bodies will help with wound healing.  This typically involves sitting in a pressurized chamber filled with oxygen for 90 minutes for multiple sessions on different days.  It is unclear whether or not HBOT is effective at preventing or treating ORN.

How is existing osteoradionecrosis (ORN) treated?

If you have ORN there are several things which can be done to help treat the disease.  Treatment of localized ORN (exposed bone) usually involves antibiotics (if infection), an antibiotic rinse, and several other medications.  Hyperbaric oxygen therapy (See above) is also commonly used.  Obvious loose pieces of dead bone are removed.  In more advanced disease, surgery may be necessary to remove non-healing areas of bone.  


Does osteoradionecrosis (ORN) get worse over time?

As you can see above, ORN is rare even in people who have been exposed to radiation; however, it is a serious condition which can be progressive in some patients (meaning it can continue to get worse over time).  


Can osteoradionecrosis (ORN) be cured?

It varies from patient to patient.  In a best-case scenario, ORN may be cured (resolve) with the treatments discussed above.  But sometimes the necrotic (dead) bone can spread, requiring surgery.  Unfortunately, in a patient with ORN, it is impossible to predict which patients will get better, stay the same, or get worse over time.  


I have a history of radiation to the head and neck.  Are there any options other than extraction for my failing tooth which can decrease the risk of osteoradionecrosis (ORN)?

In teeth with severe dental decay that are non-restorable, a procedure called root banking can sometimes be used to maintain the root of the tooth and avoid the trauma of extraction, thereby reducing the risk of ORN.  With this procedure, a root canal is performed on the root of the tooth and the tooth is structure is reduced to below the gumline. This is usually performed by an endodontist (root canal specialist) or general dentist.

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