Osteoradionecrosis (ORN)

What is osteoradionecrosis?

Osteoradionecrosis (ORN) is a condition in which bone has died due to radiation exposure. It’s a side effect of radiation therapy for cancer in your head or neck. ORN can develop months or years after radiation treatment for cancer. Symptoms of osteoradionecrosis include pain, swelling and sores.

ORN most commonly affects your lower jaw (mandibular osteoradionecrosis), but it can also occur in your upper jaw (maxillary osteoradionecrosis), the front of your spine (vertebral osteoradionecrosis) 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 blood supply to your bone. This makes it harder to heal from infection, trauma or surgery (like a tooth extraction). 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.

How common is osteoradionecrosis?

Approximately 4% to 8% of people with head and neck cancers develop osteoradionecrosis, according to the American Head & Neck Society.

What are the symptoms of osteoradionecrosis?

Symptoms of osteoradionecrosis include:

• A sore or ulcer on your gums, neck or outer jaw.
• Pain.
• Swelling.
• Infection.
• Malocclusion (misaligned teeth).
• Numbness or tingling.
• Exposed bone inside your mouth.
• Bone that sticks out through your skin (fistula), usually under your jaw.
• Broken jawbone (fracture).
• Tight jaw muscles that prevent you from opening your mouth (trismus).

What causes osteoradionecrosis?

Radiation therapy to your head and neck may result in osteoradionecrosis. 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.)

Osteoradionecrosis 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 undergoing radiation therapy.
• Develop dry mouth (xerostomia) after radiation therapy to your head and neck.
• Sustain trauma to your jaw after radiation therapy, particularly within the first year after radiation therapy.
• Have a tooth pulled in the area of previous radiation.

Osteoradionecrosis may develop several years after radiation therapy for head and neck cancers.

How is osteoradionecrosis diagnosed?

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

What tests can help diagnose osteoradionecrosis?

To confirm your diagnosis, your healthcare provider may recommend:

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

How is osteoradionecrosis treated?

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

Surgical management of osteoradionecrosis

Surgical treatments for osteoradionecrosis 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, arteries, 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. This is a specific type of free flap reconstruction. During this procedure, a surgeon takes a sheet of connective tissue (fascia) from your outer thigh and transplants it to the area that needs reconstruction. Connective tissue from your thigh is highly vascularized. This means it contains lots of blood vessels that can supply the area with vital oxygen and nutrients. According to recent research, this approach is particularly effective for people with osteoradionecrosis in their lower jaws.
• Full bone removal and replacement. Surgeons may use this traditional surgical technique when there’s a lot of dead bone, particularly in the lower jaw. It involves cutting out a segment of affected bone and replacing it with a bone-containing free flap. This procedure is effective, and surgeons still use it frequently. But it’s a much larger operation and involves long hospital stays and a lengthy recovery time. Because of this, healthcare providers aim to treat ORN in its earlier stages when possible.

Nonsurgical management of osteoradionecrosis

Nonsurgical treatments for osteoradionecrosis include:

• Antibiotics. If you have an infection in the bone or surrounding areas, your healthcare provider will prescribe antibiotics.
• PENTOCLO. This treatment combines the drug pentoxifylline, tocopherol (vitamin E) and the drug clodronate (PENTOCLO). Pentoxifylline improves blood flow to the affected bone. Tocopherol (vitamin E) boosts your immune system and prevents blood clots. Clodronate helps prevent further bone breakdown. Sometimes, healthcare providers use pentoxifylline and tocopherol without clodronate (PENTO).
• Hyperbaric oxygen (HBO) treatment. Some healthcare providers use this therapy to speed up your body’s healing process. During this treatment, you’ll enter a special chamber where you’ll breathe in pure oxygen. Inside the chamber, oxygen levels are up to three times higher than the outside environment. The main goal is to fill your blood with enough oxygen to restore damaged tissues. Hyperbaric oxygen 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.

Can I prevent osteoradionecrosis?

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 completed.
• Start using daily fluoride treatments.

During and after radiation therapy, you should:

• Practice good oral hygiene.
• Cut back on sugary foods and drinks.
• Visit your dentist regularly for exams and cleanings.
• Treat any new dental issues promptly.
• Continue daily fluoride treatments.

How fast does osteoradionecrosis progress?

In most cases, osteoradionecrosis develops slowly. Several years may go by before you notice any symptoms.

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 halt 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.

Osteoradionecrosis 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 for healing without the need for significant surgery. Some 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.

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 begin any necessary treatment promptly.

What questions should I ask my healthcare provider?

If you or a loved one has an osteoradionecrosis diagnosis, you may want to ask these questions:

• How far does the necrosis extend?
• What are my treatment options?
• Will I need surgery?
• What’s my outlook?

A note from Cleveland Clinic

Osteoradionecrosis (ORN) is a serious side effect of head and neck radiation therapy. It can take years to develop symptoms. ORN isn’t curable, but it’s manageable with treatment. Outcomes vary depending on the location, extent and severity of bone death. If you have pain, swelling, exposed bone or other osteoradionecrosis symptoms, contact a healthcare provider right away. They can recommend treatment and find ways to manage your condition.