Antibiotic therapy for the prevention of osteoradionecrosis following tooth extraction in head-and-neck cancer patients postradiotherapy: An 11-year retrospective study

Iatrogenic Head and Neck Necrosis of Bone and Soft Tissue in Cancer Patients

BACKGROUND

Cancer patients are at risk of developing a wide range of treatment-related toxicities that may affect the head and neck region. Iatrogenic necrosis of bone and soft tissue in this area represents a distinct clinical entity characterized by significant complexities and challenges, arising as a consequence of radiotherapy (osteoradionecrosis) or the administration of bone-modifying and/or antiangiogenic therapies (medication-related osteonecrosis of the jaw).

OBJECTIVE

This review provides a comprehensive understanding of this potentially highly impactful complication of cancer therapy and antiresorptive therapy by examining its pathophysiology, risk factors, clinical presentation, and management strategies.

RESULTS

Risk factors associated with these conditions include radiotherapy-related variables, medication-related factors, and local predisposing conditions.

CONCLUSION

This review highlights the importance of preventive strategies, including comprehensive dental evaluations and the development of personalized treatment plans before, during, and after cancer therapy, as well as when patients are undergoing or are expected to undergo treatment with bone-modifying medications. By addressing these critical aspects, clinicians can better manage and mitigate the impact of this challenging complication on the quality of life and morbidity outcomes.

Current trends and available evidence on low-level laser therapy for osteoradionecrosis: A scoping review

BACKGROUND

This scoping review explored current trends and available evidence in Low-Level Laser Therapy (LLLT) in the treatment and prevention of osteoradionecrosis.

METHODS

The search strategy was conducted in MEDLINE/PubMed, EMBASE, Web of Science, and grey literature on January 15, 2024, without language or time restrictions.

RESULTS

19 studies were included. The application of LLLT protocols was 58 % for therapeutic use, 21 % for preventive use, and 21 % for a combination of both. Regarding the use of antimicrobial photodynamic therapy (aPDT), 41 % of the studies employed this technique, which utilized methylene blue as the photosensitizer. For treatments associated with photobiomodulation, 57 % reported pharmacological treatment, 29 % surgical treatment, 11 % prescribed chlorhexidine mouthwashes, and 4 % other therapies. In vivo studies used diode lasers emitting low incident power densities in the near-infrared wavelength (67 %) at 780 to 904 nm. In comparison, case reports also used diode lasers emitting low incident power densities in the red and near-infrared wavelength (64 %) at 660 to 904 nm. The continuous emission mode was utilized in 83 % of in vivo studies and 17 % of the case reports. None of the studies included in this review reported all laser parameters.

CONCLUSIONS

In general, studies suggested that LLLT can be used for therapeutic and preventive applications in the management of osteoradionecrosis. However, clinical studies are case reports and the variability in laser parameters across the included studies poses challenges for establishing standardized treatment protocols. The lack of comprehensive data on laser parameters underscores the need for future research to focus on standardizing LLLT protocols and conducting well-designed, large-scale clinical trials. This approach will help to better evaluate the effectiveness of LLLT and potentially integrate it more reliably into clinical practice.

Efficacy of adjunctive modalities during tooth extraction for the prevention of osteoradionecrosis: A systematic review and meta-analysis

BACKGROUND

Jaw osteoradionecrosis (ORN) is a complication in patients with previous head and neck radiotherapy. Its incidence increases with dental extractions. Hence, this review aimed to evaluate the efficacy of adjunctive treatment modalities undertaken at the time of extraction in previous head and neck radiotherapy patients in preventing ORN.

METHODS

A systematic review was conducted, where studies with data on ORN incidence after extraction with or without adjunctive interventions were included. Meta-analyses were conducted to estimate the pooled prevalence of ORN per intervention and the pooled odds ratio for incidence of ORN between interventions.

RESULTS

In total, 1520 patients in 29 studies were included. Interventions identified were hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. The pooled prevalence of ORN for HBO (4.6%), PENTO (3.4%) and ABX (3.8%) was significantly lower than the Control (17.6%). For studies with direct comparisons between groups, HBO had lower but not significant odds of developing ORN than the Control (OR 0.27) and ABX (OR 0.57).

CONCLUSIONS

HBO, PENTO and ABX may reduce the incidence of ORN compared to no intervention. Given that all three have similar incidences of ORN, ABX may be the most cost-effective and accessible adjunctive modality.

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer.

METHODS

The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008.

RESULTS

A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation.

RECOMMENDATIONS

Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Osteonecrosis of the Jaw

Osteonecrosis of the jaw is a condition in which bone cells die due to various causes. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis. Antiresorptive or antiangiogenic drugs cause drug-induced osteonecrosis. The combination of medications, microbial contamination, and local trauma induces this condition. Osteoradionecrosis is a severe radiation therapy side effect that can affect people with head and neck cancer. It is described as an exposed bone area that does not heal for longer than three months after the end of radiation treatment with the absence of any indications of an original tumor, recurrence, or metastasis. Trauma (tooth extraction), tumor site, radiation dose that the patient receives, the area of the bone which is irradiated, oral hygiene, and other factors are risk factors for the development of osteonecrosis. Less frequently, osteonecrosis can also be induced by non-traumatic and traumatic causes. Non-traumatic osteonecrosis is brought on by infections, acquired and congenital disorders, as well as the impact of chemicals. Traumatic osteonecrosis is brought on by thermal, mechanical, or chemical damage. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient's quality of life, and surgical, which involves debridement of the necrotic bone.