However, commencement of radiotherapy should not be delayed as there is little difference in frequency of ORN in pre- and post-radiotherapy extractions and it is recommended that trauma should be kept to a minimum during extractions. Preventive regime
It is important to ensure that tooth brushing technique and habit is kept to a high standard. Patients undergoing head and neck radiotherapy may experience a sore mouth, therefore a soft bristle toothbrush may be preferred. Chlorhexidine mouthwash can also be used in conjunction with tooth brushing, and if too sore on the mucosa, can be diluted with equal amounts of water.A fluoride regime is also encouraged with either high fluoride toothpaste (Duraphat 5000), wearing splints with fluoride gel applied for 10 minutes/day or alcohol free fluoride mouthwashes. The patient’s oral condition needs to be taken into consideration and tailored accordingly as trismus may be present which would not allow the back of the mouth to be accessed by fluoride splints or trays. Some may also experience difficulty tolerating toothpastes and mouthwashes for a while due to altered taste and mucosal ulceration. It is also very important that the patient maintains a high level of motivation in taking care of their oral hygiene, and attending dental appointments where a dental practitioner will be able to monitor them during and after radiotherapy. Oral preparations prescribed to aid sore or dry mouth should be fully understood by patients to avoid any preparations which can cause damage to the teeth. Any saliva substitutes given should be pH neutral.
Surgery: The procedures involved in the surgical management of ORN are as listed: Removal of small sequestra, sequestrectomy, alveolectomy with primary closure, closure of orocutaneous fistula and large resections. Surgical management is usually required in cases of advanced disease, or if conservative measures fail to work. Methods used to reconstruct anatomical structures involve plates, autogenous bone grafts, regional flaps and free tissue transfer. Vascularised bone flaps are known to be the most effective mode of reconstruction. Therapeutic approach
Research to treat ORN at a molecular level has increased with progress in the field of medicine. The pharmacological methods to treat ORN listed below were developed to treat the etiologic factors. Pentoxifylline is methylxanthine derivative that drives vascular dilation and increased erythrocyte flexibility, resulting in enhanced blood flow. It also contains anti-tumour necrosis factor α activity, and reduces the cytokine cascade that facilitates the process of ORN. However, pentoxifylline is not meant for the long-term treatment of ORN. Tocopherols can occur in various forms. Its alpha form, also known as vitamin E, has antioxidant properties which results in the inhibition of platelet aggregation. Alpha-tocopherol is also able to scavenge reactive oxygen species involved in the ORN disease process, by inducing cell membrane peroxidation. Clodronate is a non-nitrogenous bisphosphonate used in the treatment of numerous diseases, such as hyperparathyroidism, osteoporosis, and multiple myeloma. Clodronate functions by inhibiting bone resorption, due to the reduction in the activity and quantity of osteoclasts. Clodronate also acts directly on osteoblasts, which increases bone formation and reduces the growth of fibroblasts. == References ==