gms | German Medical Science

Introduction: A systematic literature review concerning the prevention and treatment of ORN was undertaken according to evidence-based medicine (EBM) principles.

Material and methods: References were identified by a systematic PubMed search for the term “osteoradionecrosis” over the years from 1980 to 2003. The acquired results were evaluated according to the EBM criteria developed by the Cochrane Collaboration.

Results/Discussion: A total of 517 references were found (258/517 on-topic and evaluable for EBM level). 23 references concerned the diagnostics of ORN. 3 EBM level IIB and 20 EBM level III reports were found (mandible 16/23, pelvis 4/23, other 3/23). Bachmann et al. (1996) performed a prospective analysis (level IIB evidence) of the value of MRI and scintigraphy in 85 head and neck pts. Both methods were stated to be superior to conventional radiography. Store et al. (1999) found CT to be superior to panoramic radiography in determining the extent of ORN in 31 patients (level IIB). 45 references concerned the prevention of ORN. Level I evidence shows that conservation of all salvageable teeth is possible with restorative procedures, regular prophylaxis and daily fluoride. The dose to the mandible can often be reduced by conformal irradiation (level III). Post-irradiation biopsies and dental extractions increase the risk of developing ORN, especially < 12 months after radiotherapy (level III). Limited level I evidence, supported by some level III studies, indicates that if traumatic dental interventions are necessary, hyperbaric oxygen (HBO) may decrease ORN incidence. 190 reports referred to the treatment of ORN. In early and localized cases, improved oral hygiene and antibiotics were often sufficient (level III). In patients with pathological fractures, conservative treatment had a poor outcome. These conditions mostly required radical resection and reconstruction (level II). Støre et al. reported an overall success rate of 75% (88% for free grafts alone). In mandibular ORN, there is no strong evidence for the superiority of HBO – with or without surgery – over surgery alone. Of the two studies with evidence levels I or II, one is too small and the other shows no benefit for HBO. The 100% success rate from Marx et al. results from the use of radical surgery in 73%. All other large level III studies show similar results to surgery (success rates of 75-80%). There is only little evidence (level III) regarding the treatment of pelvic ORN with HBO.

Conclusion: Dental hygiene and treatment play a special role in the prevention of mandibular ORN. Traumatic intervention should be avoided. In case of trauma, HBO seems to be able to decrease ORN incidence. Concerning treatment, conservative management may be sufficient in early and localized cases. Advanced cases with fractures or bone loss require surgery. HBO (sometimes combined with sequestrectomy) is favored by some authors.