Osteoradionecrosis (ORN)

Osteoradionecrosis (ORN) is a condition in which bone has died due to radiation exposure. It’s a complication of radiation therapy for head and neck cancer. It affects 4 to 8 out of 100 people who receive radiation and can develop months or even years after treatment. Symptoms of osteoradionecrosis (os-tee-oh-rey-dee-oh-nuh-KROH-sis) include pain, swelling and sores.

ORN most commonly affects your lower jaw (mandibular osteoradionecrosis). It can also occur in your upper jaw, the front of your spine or in any other bone exposed to significant radiation.

In rare cases, ORN can affect your skull. This is a potentially fatal condition.

Radiation therapy and bone health

Radiation damages the blood supply to your bone. This makes it harder to heal from infection, trauma or surgery (like having a tooth pulled). Without a properly working blood supply, your bone and surrounding tissue:

• Are more vulnerable to infection
• Can’t heal properly
• Start to die

Your jaw is particularly at risk because of the unavoidable bone exposure to radiation during head and neck cancer treatment. Natural bacteria in your mouth further increase your risk for ORN.

In your mouth, radiation damage can cause:

• Exposed bone (bone that’s showing through your gums)
• Repeated episodes of jaw pain and swelling
• An area of tissue that doesn’t heal

Symptoms of osteoradionecrosis

Symptoms of this condition include:

• A sore or ulcer on your gums, neck or outer jaw
• Pain
• Swelling
• Infection
• Drainage
• Misaligned teeth
• Numbness or tingling
• Exposed bone inside your mouth
• Bone that sticks out through your skin, usually under your jaw
• Broken jawbone
• Tight jaw muscles that prevent you from opening your mouth

Osteoradionecrosis causes

Radiation therapy to your head and neck may result in ORN. People who receive radiation doses greater than 60 grays (Gy) are more likely to develop osteoradionecrosis. (The gray is a unit used to measure radiation.)

Risk factors

You have a higher risk of developing jaw osteoradionecrosis if you:

• Have poor oral hygiene
• Don’t address dental issues — like cavities and gum disease — before getting radiation therapy
• Develop dry mouth after radiation therapy to your head and neck
• Sustain trauma to your jaw after radiation therapy, particularly within the first year after treatment
• Have a tooth pulled in the area of previous radiation

How to lower your risk

You can’t always prevent ORN. But before you begin head and neck radiation therapy, your healthcare provider will talk with you about ways to reduce your risk for osteoradionecrosis.

Before radiation therapy, you should:

• See a dentist for a thorough cleaning and exam
• Have any necessary dental work (including extractions) completed
• Start using daily fluoride treatments

During and after radiation therapy, you should continue taking good care of your teeth. This includes practicing good oral hygiene, cutting back on sugar and continuing fluoride treatments. Schedule an appointment with your dentist immediately if any new dental issues arise.

How doctors diagnose this condition

Osteoradionecrosis often occurs several years after finishing radiation treatment. If your healthcare provider suspects ORN, they’ll examine your head and neck. They’ll likely contact your radiation oncologist to find out the total dose of radiation you received during treatment.

To confirm your diagnosis, your healthcare provider may recommend:

• Dental X-rays
• A CT scan of your jaw
• Biopsy to determine if cancer has returned (recurred)

How is ORN staged?

Staging helps healthcare providers decide the treatment you need based on how advanced the disease is. It helps them know whether you need treatment immediately or if it’s safe to “watch and wait.” They consider things like:

• The location of diseased bone or tissue, especially in relation to key head and neck structures
• Whether there’s exposed bone, including how much bone is exposed
• If there are breaks in the bone
• Your symptoms and their effects on your quality of life

Research is constantly emerging that helps providers determine disease severity and choose the best treatments in response. Your provider can explain how the osteoradionecrosis stage shapes their treatment plan for you.

How is osteoradionecrosis treated?

Treatment depends on the extent and severity of your condition. Early intervention is key. The sooner you get treatment, the better your long-term outlook. There are nonsurgical and surgical treatments that can help.

Nonsurgical management of osteoradionecrosis

Nonsurgical treatments include:

• Antibiotics: If you have an infection in the bone or surrounding areas, your healthcare provider will prescribe antibiotics.
• PENTOCLO: This treatment combines pentoxifylline, tocopherol (vitamin E) and clodronate. Together, these drugs improve blood flow to the affected bone, boost your immune system, and prevent blood clots and bone breakdown. Sometimes, healthcare providers use pentoxifylline and tocopherol without clodronate (PENTO).
• Hyperbaric oxygen (HBO) treatment: For this treatment, you’ll enter a chamber where you’ll breathe in pure oxygen. Inside, the oxygen levels are three times higher than in the outside environment. The main goal is to fill your blood with enough oxygen to heal damaged tissues.

HBO treatment is controversial among the medical community. It remains standard practice at many health centers, but there are no controlled studies that prove its effectiveness.

Surgical management of osteoradionecrosis

Surgical treatments include:

• Surgical debridement: During this procedure, a surgeon removes dead or infected bone and tissue.
• Free-flap reconstruction surgery: This procedure involves harvesting blood vessels, tissue and bone from other parts of your body and transplanting them to the area that needs reconstruction.
• ALTFL (anterolateral thigh fascia lata) rescue flap: For this type of free-flap reconstruction, your surgeon takes a sheet of connective tissue (fascia) from your outer thigh. Then, they transplant it to the area that needs reconstruction. According to recent research, this approach is especially effective for people with ORN in their lower jaws.
• Full bone removal and replacement: Surgeons mostly use this traditional technique when there’s lots of dead bone, particularly in the lower jaw. They remove a segment of affected bone and replace it with a free flap that contains bone. It’s an effective procedure. But it involves a long hospital stay and a lengthy recovery time.

When should I see my healthcare provider?

If you’ve had head and neck radiation therapy in the past and start to notice pain, swelling or ulcers, you should contact your healthcare provider right away. They can confirm whether you have osteoradionecrosis and promptly deliver the treatment you need.

What can I expect if I have this condition?

In most cases, osteoradionecrosis develops slowly. Several years may go by before you notice any symptoms. Once you do, seeing a healthcare provider as soon as possible can improve your outlook (prognosis).

Osteoradionecrosis is quite treatable. The required approach varies depending on the location of the affected bone, the extent of bone death and any previous treatments you’ve tried.

Typically, the smaller the area of affected bone, the better your chance of healing without the need for significant surgery. Sometimes, ORN doesn’t respond to minor treatments and progresses to osteomyelitis (infection of bone) or even fractures. In these instances, surgeons usually need to do larger free-flap surgeries.

Is osteoradionecrosis curable?

While surgeons can’t save dead bone, they may be able to stop the process of osteoradionecrosis with appropriate treatment. Early intervention can stop the progression of ORN in 96% of cases.

If you have osteoradionecrosis, early treatment gives you the best chance for success. Your surgery may be shorter, and you’ll likely recover more quickly. The sooner you treat ORN, the better.