Have you ever had pain, swelling, or a sore inside your mouth or jaw after undergoing radiation therapy for head or neck cancer? It may be time for you to learn about a condition called osteoradionecrosis. Don't worry, we'll talk about it in detail and in a very simple way.
What is Osteoradionecrosis (ORN)?
Simply put, osteoradionecrosis (ORN) is the death of bone cells due to exposure to radiation. It is a condition that can occur as a side effect of radiation therapy for cancer, especially head and neck cancer. Remember, the radiation used to kill cancer cells can sometimes damage healthy bone cells as well. It can occur months or even years after receiving radiation therapy.
This condition usually affects the lower jaw bone (mandibular osteoradionecrosis). However, it can occur in any bone that has been exposed to radiation, such as the upper jaw bone (maxillary osteoradionecrosis) or the front part of the spine (vertebral osteoradionecrosis). Very rarely, this condition can also affect the skull, but it can be a little more serious.
Radiation therapy and bone health - why does this happen?
Now, let's see why this happens. Radiation damages the delicate blood vessels that supply blood to the bones. Like any other part of our body, bones need a good blood supply to stay healthy and to heal quickly if they are damaged.
Just think, just like a tree withers without water, if a bone doesn't get enough blood, it too will lose its life and begin to die.
What happens when this blood supply is disrupted?
- Bones and surrounding tissues are easily susceptible to infection.
- It's impossible to heal properly.
- It's starting to die little by little.
Our jaw area is particularly vulnerable to this. This is because it is difficult to prevent radiation from reaching the jawbone during radiation therapy for head and neck cancers. Also, the risk of this `(ORN)` is further increased by the bacteria that naturally live in our mouths.
Radiation damage inside the mouth can cause things like:
- Bone exposure (meaning the bone is exposed through the gums).
- Occasional pain and swelling in the jaw .
- Having a non-healing wound .
How common is this condition?
According to the American Head & Neck Cancer Society, osteoradionecrosis may occur in between 4% and 8% of people with head and neck cancer.
What are the symptoms of osteoradionecrosis (ORN)?
Now let's see what symptoms you may experience in this situation. If you have one or more of these, it is best to seek medical advice.
- A sore or ulcer on the outside of the gums, neck, or jaw.
- Pain.
- Swelling.
- Infection (like pus).
- Teeth not fitting together properly (malocclusion).
- A tingling or tickling sensation.
- Bone fragments protruding from inside the mouth.
- Sometimes, under the chin, the skin breaks and the bone comes out (this is also called a ``fistula`').
- Jawbone fracture.
- Tightness of the jaw muscles that prevents the mouth from opening properly (trismus).
Why does osteoradionecrosis (ORN) occur?
The main cause is radiation therapy to the head and neck. This condition is especially common in people who have received radiation doses greater than 60 Gray (Gy) units. (Gy is a unit of measurement for radiation).
Osteoradionecrosis `(ORN)` Risk Factors - Who is more likely to develop it?
Some people are more at risk of developing this condition than others. See if these facts apply to you:
- Poor oral hygiene (not brushing your teeth properly, not taking care of your oral hygiene).
- If dental problems (such as cavities and gum disease) were not properly addressed before radiation treatment began.
- If you develop dry mouth (xerostomia) after radiation therapy.
- If there is any accident or injury to the jaw after radiation treatment, especially within the first year.
- If a tooth is extracted from an area that has previously been irradiated.
Remember, this condition of osteoradionecrosis can occur even years after receiving radiation treatment for head and neck cancer.
How is this diagnosed?
Osteoradionecrosis (ORN) usually occurs several years after radiation therapy. If your doctor suspects this, he or she will do a thorough examination of your head and neck. He or she will also contact the radiation oncologist who gave you the radiation therapy to find out the total dose of radiation you received.
What tests help in diagnosis?
To confirm the diagnosis, your doctor may recommend tests such as:
- Dental X-rays.
- A CT scan of the jaw (CT - computed tomography scan) is performed.
- A biopsy may be performed to check for recurrence of the cancer.
What are the treatments for this?
Treatment for osteoradionecrosis (ORN) depends on the extent and severity of your condition. The most important thing is to start treatment as soon as possible. The sooner you start treatment, the better your chances of recovery. There are both surgical and non-surgical treatments for this.
Surgical management
There are several surgeries performed for this condition:
- Surgical debridement: This is when a surgeon removes dead or infected bone and tissue, much like cleaning out a bad spot.
- Free flap reconstruction surgery: This is a slightly more complex surgery. It involves taking blood vessels, tissue, and possibly a piece of bone from another part of your body (for example, a leg or arm) and transplanting it into the damaged jaw area.
- ALTFL (Anterolateral Thigh Fascia Lata Rescue Flap): This is also a type of free flap. In this procedure, a strip of connective tissue (fascia) is taken from the back of the thigh and transplanted. This tissue is highly vascularized, allowing the damaged area to receive oxygen and nutrients. Recent studies have shown that this method is very effective in people with ORN.
- Complete bone grafting: This traditional surgical procedure is used when there is a lot of dead bone, especially in the lower jaw. In this procedure, the damaged bone is completely removed and a bone-containing free flap is grafted in its place. Although this is a successful procedure, it is a major operation. It can result in a longer hospital stay and a longer recovery time. Therefore, doctors try to diagnose and treat this condition as early as possible.
Nonsurgical management
There are also non-surgical treatments:
- Antibiotics: If there is an infection in the bone or surrounding tissues, your doctor will prescribe antibiotics.
- PENTOCLO: This is a combination of several drugs: pentoxifylline, tocopherol (vitamin E), and clodronate. Pentoxifylline works by increasing blood flow to the damaged bone. Tocopherol (vitamin E) helps to strengthen the immune system and prevent blood clots. Clodronate helps to prevent further bone loss. Sometimes pentoxifylline and tocopherol are given without clodronate (this is called PENTO).
- Hyperbaric oxygen (HBO) treatment: Some doctors use this treatment to speed up the body's healing process. In this, you are placed in a special chamber and made to breathe pure oxygen. The oxygen level inside the chamber is about three times higher than in the normal environment. The main goal is to add enough oxygen to the blood to repair damaged tissues. However, there are different opinions among the medical community about this ``Hyperbaric oxygen'' treatment. Although it is used as a standard treatment in some centers, there are still no controlled studies that have confirmed its success.
Can osteoradionecrosis (ORN) be prevented?
This condition may not always be preventable, but before you start radiation treatment to your head or neck, your doctor will talk to you about ways to reduce this risk.
Before starting radiation treatment, you should do the following:
- Visit a dentist , get your mouth cleaned thoroughly, and have a complete checkup .
- Get any dental treatment done (such as fillings, tooth extractions).
- Start daily fluoride treatment .
You should do these things during and after radiation treatment:
- Maintain good oral hygiene (brush your teeth twice daily, clean between your teeth).
- Reduce sugary foods and drinks .
- See your dentist regularly for checkups and clean your mouth.
- Get treatment for any new dental problems promptly .
- Continue daily fluoride treatment .
How quickly does osteoradionecrosis (ORN) spread?
In most cases, osteoradionecrosis (ORN) develops slowly. It may take several years for you to develop symptoms.
Can osteoradionecrosis (ORN) be cured?
Although surgeons cannot reanimate dead bone, proper treatment can halt the progression of osteoradionecrosis (ORN). It is said that if treatment is started early, the condition can be stopped in 96% of cases .
So, if you have osteoradionecrosis (ORN), starting treatment early is your best chance for success. Your surgery may be shorter, and you may recover more quickly. The sooner you treat (ORN), the better.
Osteoradionecrosis (ORN) Prognosis
Osteoradionecrosis (ORN) is a very treatable condition. The type of treatment needed depends on the location of the damaged bone, the extent of bone death, and what treatments you have tried before.
Generally, the smaller the area of bone damage, the better the chance of recovery without major surgery. Some cases of ORN may not respond to minor treatments and may progress to bone infection (osteomyelitis) or bone fractures. In such cases, surgeons may need to perform a major (free flap) surgery.
When should I see a doctor?
If you have previously had radiation therapy to your head or neck and you start to experience symptoms such as pain, swelling, or bruising, see your doctor right away. They can confirm that you have osteoradionecrosis (ORN) and start any necessary treatment quickly.
What questions should I ask my doctor?
If you or a loved one has been diagnosed with osteoradionecrosis (ORN), you may want to ask yourself these questions:
- How far has this bone necrosis spread?
- What treatment options do I have?
- Will I need surgery?
- What is my outlook (curability)?
Finally, remember (Take-Home Message)
Osteoradionecrosis (ORN) is a serious side effect of radiation therapy to the head and neck. It can take years for symptoms to appear. Although ORN cannot be completely "cured," it can be managed with treatment. Outcomes depend on the location of the damaged bone, the extent of the bone death, and the severity.
If you have pain, swelling, bone exposure, or other symptoms of osteoradionecrosis, see a doctor right away. They can recommend appropriate treatment and help you manage your condition. Maintaining good oral hygiene and seeing your dentist regularly are important for preventing and detecting this condition early.
` Osteoradionecrosis, ORN, radiation therapy side effects, jaw bone disease, cancer treatment, bone death, oral health
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