Oral appliances
Oral appliances to protrude the tongue and lower jaw forward have been used to reduce sleep apnea and snoring, and hold potential for treating UARS, but this approach remains controversial. Oral appliances may be a suitable alternative for patients who cannot tolerate CPAP. Surgery
For nasal obstruction, options can be septoplasty, turbinate reductions, or surgical palate expansion.Orthognathic surgeries that expands the airway, such as Maxillomandibular advancement (MMA) or Surgically Assisted Rapid Palatal Expansion (SARPE) are the most effective surgeries for sleep disordered breathing. MMA is often completely curative.Though less common methods of treatment, various surgical options including uvulopalatopharyngoplasty (UPPP), hyoid suspension, and linguloplasty exist. These procedures increase the dimensions of the upper airway and reduce the collapsibility of the airway. One should also be screened for the presence of a hiatal hernia, which may result in abnormal pressure differentials in the esophagus, and in turn, constricted airways during sleep. Palatal tissue reduction via radiofrequency ablation has also been successful in treating UARS. Maxillary Expansion
Orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical Rapid Palatal expansion is common in children. Due to the ossification of the median palatine suture, traditional tooth-born expanders cannot achieve maxillary expansion in adults as the mechanical forces instead tip the teeth and dental alveoli. Mini-implant assisted rapid palatal expansion (MARPE) has been recently developed as a minimally invasive option for the transverse expansion of the maxilla in adults.
Dose and delivery of radiation; generally speaking, higher doses of radiation are more likely to result in ORN, especially when doses exceed 65 Gy. While minimizing radiation doses and avoiding excess radiation to bone can reduce ORN, there does not appear to much evidence that different radiation strategies (i.e. conventional radiotherapy, IMRT, brachytherapy) reduce risk. Smoking; tobacco use is associated with significant increases in risk of developing ORN. This increased risk is attributed to the vasoconstrictive properties of nicotine, which coupled with damage to endothelium by radiation, exacerbate the decreased perfusion of affected tissues. Diabetes mellitus; diabetes is a known cause of microvascular disease, which similar to smoking, can worsen the blood supply and perfusion to tissues affected by radiation. Dental disease and extractions; patients with poor oral hygiene and dental disease prior to radiation, including edentulous patients and those with dentures, are more susceptible to developing ORN. Diseased teeth near the radiation field may need to be extracted, and should be evaluated prior to radiation treatment. Staging
The staging system can be useful as a baseline reference for management after a definitive diagnosis of ORN has been established. Prevention and management
There is currently no universally accepted prevention and management of ORN and in many cases depends on how severe the condition presents. Currently, there are many preventive approaches for ORN proposed, but yet to be justified by high quality evidence. Studies have been conducted to measure effectiveness of current interventions. However, there lacks evidence to conclude that one approach is more effective than others.