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Review
, 2019 (11)

Interventions for Preventing Osteoradionecrosis of the Jaws in Adults Receiving Head and Neck Radiotherapy

Review

Interventions for Preventing Osteoradionecrosis of the Jaws in Adults Receiving Head and Neck Radiotherapy

Mohamed El-Rabbany et al. Cochrane Database Syst Rev.

Abstract

Background: Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation-induced fibro-atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified.

Objectives: To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non-palliative) radiotherapy.

Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

Selection criteria: We selected randomised controlled trials (RCTs) or quasi-RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre- or post-irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions.

Data collection and analysis: Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane.

Main results: Four studies were identified that met pre-determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet-rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low-certainty evidence). Another study involved comparing fluoride gel and high-content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post-radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low-certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low-certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low-certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important.

Authors' conclusions: Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well-designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions.

Conflict of interest statement

Mohamed El‐Rabbany: none known. Michael Duchnay: none known. Hamid Reza Raziee: none known. Maria Zych: none known. Howard Tenenbaum: none known. Prakeshkumar S Shah: none known. Amir Azarpazhooh: none known.

Update of

  • Cochrane Database Syst Rev. doi: 10.1002/14651858.CD011559

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References

References to studies included in this review

    1. Batstone MD, Cosson J, Marquart L, Acton C. Platelet rich plasma for the prevention of osteoradionecrosis. A double blinded randomized cross over controlled trial. International Journal of Oral and Maxillofacial Surgery 2012;41(1):2‐4. - PubMed
    1. Horiot JC, Schraub S, Bone MC, Bain Y, Ramadier J, Chaplain G, et al. Dental preservation in patients irradiated for head and neck tumours: a 10‐year experience with topical fluoride and a randomized trial between two fluoridation methods. Radiotherapy and Oncology 1983;1(1):77‐82. - PubMed
    1. Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: a randomized prospective clinical trial of hyperbaric oxygen versus penicillin. Journal of the American Dental Association 1985;111(1):49‐54. - PubMed
    1. Schoen PJ, Raghoebar GM, Bouma J, Reintsema H, Vissink A, Sterk W, et al. Rehabilitation of oral function in head and neck cancer patients after radiotherapy with implant‐retained dentures: effects of hyperbaric oxygen therapy. Oral Oncology 2007;43(4):379‐88. - PubMed

References to studies excluded from this review

    1. Papas A, Russell D, Singh M, Kent R, Triol C, Winston A. Caries clinical trial of a remineralising toothpaste in radiation patients. Gerodontology 2008;25(2):76‐88. - PubMed
    1. Toljanic JA, Siddiqui AA, Patterson GL, Irwin ME. An evaluation of a dentifrice containing salivary peroxidase elements for the control of gingival disease in patients with irradiated head and neck cancer. Journal of Prosthetic Dentistry 1996;76(3):292‐6. - PubMed

References to studies awaiting assessment

    1. Shaw RJ, Butterworth CJ, Silcocks P, Tesfaye BT, Bickerstaff M, Jackson R, et al. HOPON (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis): a randomized controlled trial of hyperbaric oxygen to prevent osteoradionecrosis of the irradiated mandible after dentoalveolar surgery. International Journal of Radiation Oncology, Biology, Physics 2019;104(3):530‐9. - PubMed

Additional references

    1. Ahmed M, Hansen VN, Harrington KJ, Nutting CM. Reducing the risk of xerostomia and mandibular osteoradionecrosis: the potential benefits of intensity modulated radiotherapy in advanced oral cavity carcinoma. Medical Dosimetry 2009;34(3):217‐24. - PubMed
    1. Boje RC, Dalton SO, Gronborg TK, Primdahl H, Kristensen CA, Andersen E, et al. The impact of comorbidity on outcome in 12,623 Danish head and neck cancer patients: a population based study from the DAHANCA database. Acta Oncologica 2013;52(2):285‐93. - PubMed
    1. Chang EI, Leon P, Hoffman WY, Schmidt BL. Quality of life for patients requiring surgical resection and reconstruction for mandibular osteoradionecrosis: 10‐year experience at the University of California San Francisco. Head & Neck 2012;34(2):207‐12. - PubMed
    1. Clayman L. Clinical controversies in oral and maxillofacial surgery: part two. Management of dental extractions in irradiated jaws: a protocol without hyperbaric oxygen therapy. Journal of Oral and Maxillofacial Surgery 1997;55(3):275‐81. - PubMed
    1. Curtin F, Elbourne D, Altman DG. Meta‐analysis combining parallel and cross‐over clinical trials. II: Binary outcomes.. Statistics in Medicine 2002;21(15):2145‐59. - PubMed

References to other published versions of this review

    1. Duchnay M, Tenenbaum H, Wood R, Raziee HR, Shah PS, Azarpazhooh A. Interventions for preventing osteoradionecrosis of the jaws in people receiving head and neck radiotherapy. Cochrane Database of Systematic Reviews 2015, Issue 2. [DOI: 10.1002/14651858.CD011559] - DOI

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