We have seen lots of patients over the years with ORN here, I am one of them. There are two approaches depending on when you become aware of it. First I would just like to make clear that ORN is visible in common X-rays, panoramic ones taken at an oral surgeons office or the small PA’s taken at a dental office. It is unmistakable and obvious to anyone who knows what they are looking at, but not always to general dentists that see it but often think it is bone loss around teeth from periodontal disease. It can initially appear small but progresses as the bone, damaged by radiation and losing its micro vascularization begins to die and become necrotic.it happens mostly in the mandible, less so in the maxilla.
In its very early discovery stages in some people there is an opportunity to halt it even reverse it. But not in all cases. This is very dependent on individual biology and the number of gy’s of radiation the patent was exposed to, and the field if radiation. People radiated even in the early days of IMRT radiation did not have great mapping of the fields. When the technology was newly introduced, it was many years before ROs started using it to its full advantage. The reason for this was in order to fully utilize its capabilities, you had to know head and neck anatomy the way a surgeon knows it which is far beyond radiation oncologists training. Radiation oncology took many years to get up to speed.
The things which can be tried to reverse or slow down the process are the use of pentoxifyline combined with vitamin E. You can Google search this, and there are numerous peer reviewed articles from around the world showing varying degree of success. I tried this unsuccessfully, but the caveats are that I went through treatment back when XMRT poorly targeted radiation was the standard of care and had 72 by of radiation, far more than is given today. Others that have tried this have in early stages of ORN reversed the bone loss. The mechanism of action is an increase in micro capillaries in the bone. Pentoxifyline is a vasodilator and contributes to increased angiogenesis systemically, not just in the bone. There are few side effects from using it, some people report lightheadedness from the vasodilation and drops in blood pressure. Working on modifying dosage which is usually about 400 mg twice a day mitigate this issue.
An expensive and not always successful, and not always insurance covered idea is hyperbaric oxygen treatments. Not alway impactful in treating ORN and the literature is mixed. I have seen this work to reverse ORN in people that went through the process with me. They had smaller areas that in radiographs and you could see it disappear in subsequent images over about 35 dives. Again my experience was not successful likely for the reasons previously stated.
I ultimately had a fibula free flap 10 hour surgery to replace the left side of my mandible last summer at Johns Hopkins. Any one that wants to know about it and the potential benefits and negative outcomes compared, I would be happy to explain my experience to you. Even for its reputation, I would choose a different institution to have this done at if I could go back in time.
I hope this is somewhat helpful. From any perspective this is a crappy place to end up. But there are several hundred fib free flaps done a year in the US with really good outcomes.
I have a background as a Founder and CEO of a FDA regulated class three medical device company that designed and fabricated dental implants, and have lectured and taught extensively about them. I designed FDA approved implantable devices and the components used to restore them. Their success rates in radiated bone are poor. Over twenty years of working w cancer patients on post treatment implant use I have seen far more expensive failures than successes. Again happy to elaborate if someone wishes to understand it all more fully. But I will stop here so this doesn’t turn into a book.
