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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] - Oral Toxicities Not Related to Chemotherapy or Radiation Therapy

Table 5. Drugs and Biologics Used in Oncology and Reported to Be Associated With ONJ continued...

The use of hyperbaric oxygen therapy (HBO) to treat cases of established ONJ does not appear to be effective.[4,13,24,25] However, evidence indicates that HBO in addition to discontinuation of bisphosphonate therapy may benefit patients with ONJ.[31] Definitive evidence is pending while research in this area continues.[32]

Another possible approach involves surgical manipulation and uses bone labeling with tetracycline. In this modality, the patient is treated with a standard dose of tetracycline a few days presurgery. During the surgery, when bone is exposed, the Wood's lamp is shone over the bone. Necrotic bone does not fluoresce and is removed. The procedure continues until fluorescence is seen, suggesting the presence of vital bone.[33]

The American Association of Oral and Maxillofacial Surgeons proposed a staging system for ONJ and suggested treatment strategies (see Table 6, adapted from the guidelines paper [34]).

Table 6. ONJ Staging System

BRONJ (ONJ) StagingTreatment Strategies
BRONJ = bisphosphonate-related osteonecrosis of the jaw; IV = intravenous; ONJ = osteonecrosis of the jaw associated with medications.
At-risk category: No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates.No treatment indicated; patient education.
Stage 0: No clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms.Systemic management, including the use of pain medication and antibiotics.
Stage 1: Exposed and necrotic bone in patients who are asymptomatic and have no evidence of infection.Antibacterial mouth rinse; clinical follow-up on a quarterly basis; patient education and review of indications for continued bisphosphonate therapy.
Stage 2: Exposed and necrotic bone associated with infection, as evidenced by pain and erythema in the region of the exposed bone, with or without purulent drainage.Symptomatic treatment with oral antibiotics; oral antibacterial mouth rinse; pain control; superficial debridement to relieve irritation of soft tissue.
Stage 3: Exposed and necrotic bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone (i.e., inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla), resulting in pathologic fracture, extraoral fistula, oral antral/oral nasal communication, or osteolysis extending to the inferior border of the mandible of sinus floor.Antibacterial mouth rinse; antibiotic therapy and pain control; surgical debridement/resection for longer-term palliation of infection and pain.
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