Osteoradionecrosis (ORN) of the Jaw – Treatment, Definition, Radiology, Symptoms, Classification, ICD-10

Key Facts

• Osteoradionecrosis (ORN) is a severe bone disease that arises as a side effect of radiation therapy primarily used to treat head and neck cancers
• ORN primarily affects the jaw, especially the mandible
• It is one of the most severe complications of radiation therapy
• High doses of radiation can compromise the bone’s blood supply, leading to necrosis
• Adequate dental care before radiation therapy and avoiding trauma to irradiated areas can reduce the risk
• Depending on severity, treatments can range from medication and hyperbaric oxygen therapy to surgical interventions

What is Osteoradionecrosis?

Osteoradionecrosis, often abbreviated as ORN, is a condition where bone starts to deteriorate and die after radiation therapy. This condition predominantly affects the jawbones, especially the lower jaw or mandible. The decay happens because radiation, while killing cancer cells, can also damage healthy cells and reduce the blood supply to the bone.
When the bone doesn’t receive adequate blood, it can’t get the necessary oxygen and nutrients it needs to repair and maintain itself. As a result, sections of the bone begin to die. This process can be exacerbated by injuries, infections, or dental procedures in the irradiated area, leading to a cycle of chronic non-healing wounds.
Patients who have received radiation therapy for head and neck cancers are at the highest risk. The onset can be immediate, within months of the radiation treatment, or delayed, occurring many years later.
The management and prevention of ORN require a multidisciplinary approach, often involving dental surgeons, oncologists, and specialists in hyperbaric medicine. Recognizing the condition early and starting intervention can prevent its progression and improve outcomes.

How Radiation Damages Blood Supply to Your Bone

Radiation therapy is a crucial tool in the treatment of various cancers. It works by using high doses of radiation to kill cancer cells or shrink tumors. While effective against cancer cells, radiation can also affect nearby healthy tissues, including bone and its blood supply.

• Direct Cellular Damage: Radiation targets rapidly dividing cells, a characteristic of cancer cells. However, cells responsible for bone repair and regeneration, such as osteoblasts and osteoclasts, can also be affected. The damage to these cells impairs bone turnover, repair, and remodeling.
• Vascular Damage: A vital concern with radiation therapy and bone health is the effect on blood vessels. The radiation can cause endarteritis, a condition where the inner linings of small blood vessels become inflamed. This inflammation can lead to the narrowing or even occlusion of these vessels. When this occurs in the vessels supplying the bone, it can compromise blood flow, depriving the bone of essential nutrients and oxygen. Over time, this lack of blood supply can lead to areas of necrotic, or dead, bone.
• Fibrosis: Radiation can stimulate the production of fibrous tissues. This fibrotic tissue can replace both normal bone marrow tissue and blood vessels, further impeding blood flow to the bone.
• Decreased Bone Density: Long-term effects of radiation can also include a decrease in bone density in the irradiated area. Reduced bone density makes the bone more susceptible to fractures and other injuries.

How Common is Osteoradionecrosis?

Osteoradionecrosis (ORN) is one of the more severe complications arising from radiation therapy, especially in treatments involving the head and neck region. The prevalence of ORN varies, but studies suggest that the risk is between 2% to 22% for patients who have undergone radiation therapy for head and neck cancers.
Several factors influence this variability, such as:

• Dose of Radiation: Higher doses of radiation are linked to a greater risk of developing ORN.
• Location of Treatment: Areas with limited blood supply, like the mandible, are more prone to ORN than other parts of the body.
• Trauma: Dental extractions or other trauma to irradiated areas can precipitate or exacerbate ORN.
• General Health and Other Medical Conditions: Patients with conditions like diabetes or those who smoke may have an increased risk of developing ORN.

Symptoms of Osteoradionecrosis

Symptoms can range from mild to severe, depending on the stage of the condition. Common symptoms include:

• Pain: Often, the first and most common symptom reported is pain in the affected area.
• Exposed Bone: As the condition progresses, areas of exposed bone may become visible, especially in regions like the mouth.
• Swelling and Inflammation: The affected areas may exhibit signs of inflammation, including redness, warmth, and swelling.
• Mouth Ulcers: Non-healing ulcers may develop, particularly if the jawbone is affected.
• Pus or Foul-smelling Discharge: This can be indicative of a secondary infection in the necrotic bone area.
• Difficulty Opening the Mouth: If the jawbone is involved, individuals might have trouble opening their mouth, a condition known as trismus.
• Tooth Loosening: Teeth may become loose in the affected region.
• Fracture: In advanced cases, the weakened bone might fracture or break.

Causes of Osteoradionecrosis and Risk Factors

Osteoradionecrosis is primarily caused by radiation therapy, which damages the blood vessels supplying the bone, leading to hypoxia (lack of oxygen), cell death, and eventually bone necrosis.
Various factors can increase the risk of developing ORN:

• High Doses of Radiation: Higher doses of radiation to treat tumors can increase the risk. Specifically, doses exceeding 60 Gy are associated with a higher likelihood of ORN.
• Radiation Field: Areas with limited natural blood supply, such as the lower jaw (mandible), are more susceptible.
• Dental Procedures: Dental extractions or invasive dental procedures in the irradiated area can increase the risk due to trauma.
• Poor Oral Hygiene: A lack of regular dental care and poor oral hygiene can exacerbate the risk, especially if there’s a presence of chronic dental disease.
• Underlying Medical Conditions: Conditions like diabetes, anemia, and malnutrition can make tissues more vulnerable to radiation damage.
• Tobacco and Alcohol Consumption: Both tobacco and excessive alcohol use can reduce blood flow to the tissues, increasing the risk of ORN.
• Concurrent Chemotherapy: When radiation therapy is combined with certain chemotherapeutic agents, the risk of developing ORN might increase.

Diagnosis and Testing for Osteoradionecrosis: How is Osteoradionecrosis Diagnosed?

Osteoradionecrosis (ORN) often presents with a unique combination of clinical symptoms and a history of radiation therapy, making it distinct from other conditions. The diagnosis is primarily clinical, based on a thorough examination, patient history, and supported by specific tests.

• Medical and Dental History: The first step in diagnosing ORN involves obtaining a comprehensive medical and dental history. A history of radiation therapy, especially to the head and neck region, combined with the presence of related symptoms, raises suspicion for ORN.
• Clinical Examination: During the physical examination, the healthcare provider will look for exposed bone that does not heal within a specific timeframe (usually 3-6 months). They’ll also assess other signs like swelling, redness, pus, ulcers, or loose teeth in the affected area.

What Tests Can Help Diagnose Osteoradionecrosis?

While the diagnosis of ORN is primarily clinical, various imaging and diagnostic tests can help confirm the condition, assess its severity, and differentiate it from other disorders:

• X-rays (Radiographs): Standard dental or panoramic X-rays can provide an overview of the bone structure and show changes consistent with ORN, such as bone degradation, sequestra (fragments of dead bone), or pathologic fractures.
• Computed Tomography (CT) Scan: CT scans offer a detailed view of the bone and surrounding tissues, highlighting areas of necrosis, sequestra, or infections.
• Magnetic Resonance Imaging (MRI): MRI can be useful to visualize soft tissue changes and assess the extent of the condition, especially in advanced cases where soft tissue involvement is suspected.
• Bone Scintigraphy: This involves injecting a small amount of radioactive material into the bloodstream, which then accumulates in areas of bone turnover. A special camera detects this radiation and creates an image of the bones, helping identify regions affected by ORN.
• Biopsy: In uncertain cases or to rule out malignancy, a small tissue sample may be taken from the affected area and examined under a microscope.
• Blood Tests: While not specific to ORN, blood tests can assess overall health, check for signs of infection, and monitor levels of nutrients important for bone health.

It’s crucial to note that while these tests can provide valuable information, the diagnosis of osteoradionecrosis remains fundamentally clinical, relying heavily on patient history and physical examination findings. Early diagnosis and timely intervention are paramount for managing ORN and preventing its progression.

Treatment of Osteoradionecrosis (ORN)

Osteoradionecrosis (ORN) is a challenging condition to treat because of its multifactorial nature. A comprehensive treatment approach is often necessary, involving both nonsurgical and surgical methods. The severity of the disease and the patient’s overall health can dictate the most appropriate treatment strategy.

Nonsurgical Management of Osteoradionecrosis

• Hyperbaric Oxygen (HBO) Treatment: HBO therapy involves breathing pure oxygen in a pressurized room or chamber. The increased pressure allows more oxygen to enter the bloodstream, which can promote wound healing and fight infection. HBO can help stimulate the growth of new blood vessels in irradiated tissues, enhancing the healing process in ORN-affected areas.
• Antibiotics: Infection can be a complicating factor in ORN. Prolonged courses of antibiotics might be prescribed to manage or prevent infections, especially if there’s exposed necrotic bone.
• PENTOCLO: This refers to a regimen comprising pentoxifylline and tocopherol, which has shown promise in managing ORN. This combination may help reduce inflammation and promote healing by improving blood flow.
• Pain Management: Analgesics and anti-inflammatory medications can help manage pain and discomfort associated with ORN.
• Oral Care: Maintaining excellent oral hygiene is paramount. Specialized mouthwashes can help keep the oral environment clean and reduce bacterial load.

Surgical Management of Osteoradionecrosis

• Surgical Debridement: This is the removal of necrotic (dead) bone tissue. In mild to moderate cases of ORN, surgical debridement may be sufficient to manage the condition. The goal is to remove non-viable bone and promote the healing of surrounding tissues.
  • Sequestrectomy: This is a specific type of debridement where segments of dead bone (sequestra) that have become detached from the surrounding bone are removed.
  • Free Flap Reconstruction Surgery: In severe cases of ORN, significant bone and soft tissue loss may occur. Free flap reconstruction involves transferring tissue (including skin, muscle, and sometimes bone) from another part of the body to the affected area, re-establishing blood flow and promoting healing.
  • Bone Grafting: In situations where there’s significant bone loss, bone grafting might be necessary. This involves taking bone from another part of the body or using synthetic materials to replace the missing or damaged bone.
  • Endodontic Treatments: In certain situations, root canal treatments might be necessary to manage or prevent the progression of ORN.

  The treatment for ORN is highly individualized. The choice of management—whether nonsurgical, surgical, or a combination of both—depends on the disease’s severity, the affected bone’s location, and the patient’s overall health. Early detection and prompt treatment are vital to achieve favorable outcomes and prevent complications.

  Can I Prevent Osteoradionecrosis?

  Prevention of ORN, especially in patients who are at risk, is of utmost importance.
  Here are some preventive measures:

  • Dental Evaluation: Before starting radiation therapy, have a thorough dental examination. Extract any teeth that are decayed or in poor condition, as they could become sources of infection after radiation.
  • Maintain Oral Hygiene: Regularly brushing, flossing, and using appropriate mouthwashes can help maintain a clean oral environment, reducing the risk of infections that can lead to ORN.
  • Avoid Trauma: Minimize any trauma to the oral tissues, including ill-fitting dentures or rough foods, as trauma can precipitate ORN in radiated tissues.
  • Regular Dental Check-ups: Post-radiation, regular visits to the dentist are crucial. Early detection of dental problems can help in early management, potentially preventing ORN.
  • Fluoride Treatment: Use of fluoride gels or rinses can help strengthen teeth, reducing the risk of decay in irradiated patients.

  How Fast Does Osteoradionecrosis Progress?

  The progression of ORN is variable and depends on several factors, including the radiation dose, site of radiation, patient’s overall health, and whether there was any trauma or infection in the area. ORN might appear within a few months of radiation or could be delayed by several years. Its progression can be slow, but once started, if left untreated, ORN can lead to significant destruction of the jawbone over time.

  Can Osteoradionecrosis Be Cured? – Osteoradionecrosis Prognosis

  The prognosis for ORN varies depending on its severity and the timeliness of its treatment.

  • Early Intervention: If detected and managed early, the outcomes are generally favorable. The necrotic bone can be removed, and with adequate care, the surrounding tissues can heal well.
  • Advanced ORN: In more advanced cases, where there’s significant bone and soft tissue loss, comprehensive treatments, including surgical interventions, may be required. The prognosis in these cases can be more guarded, but with the right management, patients can achieve symptom relief and functional restoration.
  • Comprehensive Care: It’s not just about treating the ORN but also about addressing any other underlying health conditions, nutritional needs, and providing adequate pain management.

  When Should I See My Healthcare Provider?

  • Initial Symptoms: At the first sign of persistent pain, swelling, or exposed bone in the area that received radiation.
  • Change in Symptoms: Any increase in pain or discomfort, presence of pus, or foul-smelling discharge from the mouth.
  • Difficulty in Function: If you find it hard to open your mouth, chew, swallow, or speak.
  • Other Symptoms: Presence of numbness or tingling in the chin or lower lip, suggesting nerve involvement.
  • Routine Check-ups: Regular follow-ups after radiation therapy, as some complications may not manifest immediately.

  What Questions Should I Ask My Healthcare Provider?

  • What exactly is osteoradionecrosis, and how severe is my condition?
  • What are the treatment options available? What are the benefits and risks of each?
  • What steps can I take to prevent further complications?
  • What potential side effects should I watch out for during treatment?
  • Are there any dietary changes, supplements, or habits that can help in my recovery?
  • Would it be beneficial for me to see a specialist, like a maxillofacial surgeon or an oncologist?
  • How long will the treatment last, and what is the expected recovery time?
  • How often should I return for check-ups, and what will these involve?
  • In what situations should I seek emergency care?
  • How much will the treatment cost, and will my insurance cover it?

  Osteoradionecrosis (ORN) ICD-10 Code

  ICD-10 diagnosis code for Osteoradionecrosis (ORN) is M27.2 – Inflammatory conditions of jaws.

  This ICD-10 code is applicable to the following conditions:

  • Osteitis of jaw(s)
  • Osteomyelitis (neonatal) jaw(s)
  • Osteoradionecrosis jaw(s)
  • Periostitis jaw(s)
  • Sequestrum of jaw bone

  Bottom Line

  Osteoradionecrosis (ORN) is a severe side effect of radiation therapy that affects the bone’s health. If you have undergone radiation treatment, especially in the head and neck regions, being vigilant about oral symptoms and maintaining regular dental check-ups is crucial. Early detection and treatment can significantly improve outcomes and quality of life. Being informed, asking the right questions, and actively participating in your care can make a considerable difference in your ORN journey. Always prioritize your health and never hesitate to seek professional guidance when in doubt.

  This article is complete and was published on October 21, 2023, and last updated on October 25, 2023.