Joshua, JH Kim
| Joshua, JH Kim |
Joshua JH Kim, Jason Tong
Rania Habib
Oral and Maxillofacial Surgery, University of Pennsylvania School of Dental Medicine
Introduction
Osteoradionecrosis (ORN) is a rare complication that can arise in patients following radiation therapy of the head and neck region. Traditional ORN prophylactic management of patients requiring dental extractions treated with radiotherapy for head and neck cancer consists of hyperbaric oxygenation therapy (HBOT) or post-antibiotic treatment. Current studies have shown that uses of HBOT or antibiotic prophylaxis decreased ORN incidence from 7% to 4% and 6% respectively. Recently, the radiation-induced fibroatrophic process (RIF) theory proposed by Delanian and Lefaix has challenged the existing theories of ORN pathophysiology. They proposed that ORN is the result of inflammation, free radicals and fibroblast overactivation, resulting in tissue fibrosis post radiotherapy. This new theory paved the way for a new treatment regimen consisting of pentoxifylline and tocopherol (PENTO). Pentoxifylline increases tissue oxygenation and tocopherol has antioxidant effects, thus synergistically decreasing radiation-induced fibrosis. Many studies have shown encouraging effects of pentoxifylline, tocopherol, and clodronate (PENTOCLO) in treating patients with ORN; however, there are very limited studies indicating uses of PENTO prophylactically to prevent the incidence of ORN. This literature review aims to highlight and review the efficacy of PENTO prophylactic use to reduce ORN incidence following dental extractions in patients with prior radiation therapy of the head and neck region.
Methods
We performed a literature review using various databases including PubMed and Google Scholar to identify existing protocols for the prophylactic use of PENTO. We qualitatively analyzed two retrospective studies, and reviewed the methodology described in Patel et al. and Aggarwal et al.
Results
Patel et al. performed a retrospective study on 390 dental extractions in 82 patients who had radiotherapy for head and neck cancer. Patients were given prophylactic pentoxifylline 400mg twice daily and tocopherol 1000 IU daily. The average duration of PENTO prophylaxis was 11 weeks prior to dental extractions with a standard deviation of 23 weeks and 13.6 weeks postoperatively with a standard deviation of 18 weeks. In Patel et al. only 1 patient developed ORN (1.2%).1 Aggarwal et al. also performed a retrospective study with 450 dental extractions in a total of 110 patients who had radiotherapy for head and neck cancer. In this study, patients were given pentoxifylline 400mg twice daily and tocopherol 1000 IU daily. The average duration of prophylaxis use of PENTO was 12 weeks prior to dental extractions with a standard deviation of 24 weeks and 14 weeks postoperatively with a standard deviation of 18 weeks. In Aggarwal et al. only 2 patients developed ORN.2
Conclusion
Both retrospective studies, Patel et al. and Aggarwal et al., analyzed and evaluated PENTO prophylaxis in patients treated with radiotherapy for head and neck cancer. Patel et al. found an ORN incidence of 1.2% with prophylactic PENTO use. Currently, there is a lack of prospective studies that confirm a strong association between PENTO prophylactic use and decreased ORN incidence. Yet, these retrospective studies show promising results.