Surgical Treatment With Hyperbaric Oxygen in the Management of Bisphosphonate-related Osteonecrosis of Jaw
HAMADA, S; NAKAHARA, H; ENOMOTO, A; UEDA, T; UCHIHASHI, T; SHIMOIDE, T; MORIKAGE, E; NAKATANI, T, MORIGUCHI , KIMURA, S; NAKABAYASHI, Y; HIGA, Y; YOSHIOKA, H*; TOKUMIYA, M.*
Department of oral and maxillofacial surgery, Kinki University Hospital
Department of oral and maxillofacial surgery, Osaka Rosai Hospital *
The first preliminary report of bisphosphonate(BP)-related osteonecrosis of jaw (BRONJ) was published by Marx in 2003, and many patients suffering from severe BRONJ have since been identified. Hyperbaric oxygen (HBO) is recognized as useful to treat post-radiation osteonecrosis of the jaw, but few recommendations currently exist for the use of HBO to treat BRONJ, and opinions regarding efficacy are conflicting. Freiberger et al. conducted a randomized controlled study, but lacked the statistical power to show a significant difference between using and not using HBO in complete healing (ref. 1, 2). We report herein an excellent treatment outcome for patients with BRONJ using a combination of surgical treatment and HBO, and antibiotics with cessation of further BP use.
Before this study, we obtained ethics committee approval from the Faculty of Medicine at Kinki University. According to the diagnostic criteria set by AAOMS, BRONJ was diagnosed in three patients. The clinical course, laboratory data and diagnostic imaging including X-ray, CT and MR imaging and pathological diagnoses of the three cases were analyzed and compared both to each other and to the literature. Criteria for resolution include closed soft tissues, no pain, and improved or stable findings on imaging.
Case 1: A 76-year-old woman was referred to our department with severe spontaneous pain of the right lower alveolus with widespread sequestrum, and buccal skin fistula formation. She had received BP therapy with zorendronate in the management of multiple myeloma. Removal of sequestrum was performed in combination with 20 sessions of preoperative HBO, antibiotics with cessation of further BPs. Regeneration of the mandible was observed from residual periosteum and reconnection of the separated mandible and satisfactory function were obtained.
Case 2: A 78-year-old woman was referred to our department with seqestrum formation in the mandiblar alveolus and spontaneous pain. She had received BP therapy with zorendronate in the management of multiple myeloma. Marginal resection of the mandible was carried out in combination with 20 pre and 20 post sessions HBO, antibiotics, and cessation of further BPs.
Case 3: A 76-year-old woman was referred to our department with pus discharge from the gingiva of the left lower jaw and buccal skin fistula formation. She had received BP therapy with alendronate in the management of osteoporosis. Removal of sequestrum was performed in combination with 10 sessions of preoperative HBO, antibiotics and cessation of further BPs.
We encountered three cases with BRONJ that were treated using surgery with HBO. In all cases symptoms resolved on follow-up.
The value of surgery with HBO for the treatment BRONJ is suggested. It seems important to achieve sequestrum separation preoperatively, and preoperative HBO may accelerant this process, while postoperative HBO may accelerate residual bone healing.
Reference:
Freiberger J.: Utility of hyperbaric oxygen therapy in treatment of Bisphosphonate-related osteonecrosis of the jaw. J Oral Maxillofac Surg 67: 96-106,2009, (Suppl 1)
Freiberger J., et al: What is the role of hyperbaric oxygen in the management of Bisphosphonate-related osteonecrosis of the jaw: a randomized controlled trial of hyperbaric oxygen as an adjunct to surgery and antibiotics. J Oral Maxillofac Surg 70: 1573-1583,2012
Conflict of Interest (COI) of the Principal PresenterFNo potential COI to disclose.