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Hyperbaric oxygen therapy
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Letters to the editor
265
Volume 81, Number 3
In Reply We are grateful for the interest Dr. Dodson has shown in our article entitled, Relationship between fractures of the mandibular angle and the state of eruption of the lower third molar, and note his comments. His analysis of our data as presented in his table is flawed. H o w e v e r it does confirm a trend relating increased risk of angle fracture to depth of impaction; the only deviation being with our group classified with an impaction score of 6 and this could be attributable to the low numbers in this subset. The method of analysis we employed (Chi-squared test for linear trends in proportions) was one that is sensitive to trends and confirms our conclusions. Nevertheless it is obvious that such sensitivity, although of academic interest, is of little clinical value when compared with the influence the presence of a third molar tooth has on angle weakness, which both Dr. Dodson's study and our own have demonstrated. Nadim Safdar John G. M e e c h a n
Department of Oral Surgery The Dental School Newcastle upon Tyne, U.K.
Hyperbaric oxygen therapy Letter to the editor:
We welcome the addition to the literature of Dr. van Merkesteyn et al., Hyperbaric oxygen treatment of osteoradionecrosis of the mandible: Experience in 29 patients, that was recently published (ORAL SURG ORAL MED ORAL PATHOL 1995;80:12-6.). The purpose we have in submitting this letter is to clarify their reference to our previous studies and to enhance the discussion regarding management of necrosis of the jaw after radiation therapy and the value of hyperbaric oxygen therapy. Agreement on the criteria for assessing the clinical status of patients is needed. We have previously published a clinical scale to allow a staging of necrosis so that therapy can be chosen and reports of outcomes of therapy may be facilitated. 1 This clinical description allows an understanding of resolved cases with or without previous pathologic fracture and with or without continuity of the mandible being achieved, chronic nonprogressive exposure of bone with or without mandibular discontinuity, and active progressive and symptomatic necrosis. The difficulty in assessing different criteria for resolution of necrosis is evident upon reading of the
recent article by Dr. van Merkesteyn et al. In this article the authors concluded that 20 of 29 patients with necrosis were considered to be resolved after treatment. The authors in fact reported on 27 patients, as only 27 of the original 29 patients were treated with hyperbaric oxygen therapy. As their study was of hyperbaric oxygen treatment, the two patients who did not receive hyperbaric oxygen therapy should not be included in percentage outcomes of the cases that had been treated with hyperbaric oxygen therapy. Criteria for resolution included closure of soft tissues, no pain, and improvement or stable findings on radiographs. However, these findings were not described in detail within the article. If their treatment outcomes would have been assessed with more strict criteria that included maintenance of continuity of the mandible and closure of soft tissues as has been suggested by Marx, 2 the outcome of their therapy would be considerably worse. Indeed 13 patients experienced discontinuity of the mandible at referral; 2 patients showed healing after their treatments and five additional patients lost mandibular continuity during treatment. This indicates that 60% (16 of 27) of patients treated in their study population experienced discontinuity of the mandible at the end of the study period. The authors then compared the results of their study with the outcome of a treatment of a series of cases that we bad reported at a time when hyperbaric oxygen therapy was not a consistent part of the management approach at our institution.l In their review of our study they note that 15% of patients have resolution and 42% stabilized after clinical treatment; hyperbaric oxygen was part of management in two cases. In this study we also reported the results of episodes of clinical necrosis that showed 33% were resolved, 15% were improved, 42% were stable, and 9% were worse. We began regular institution of hyperbaric oxygen therapy in these patients as reported in 1993. 3 In this study, 26 patients were diagnosed and treated with hyperbaric oxygen therapy. All but eight patients received some form of surgical management. A median of 35 sessions of hyperbaric oxygen therapy was administered. The results of this study were that 18 of 26 patients achieved persistent mucosal and cutaneous coverage, 13 of 26 met strict criteria of resolution of the disease process, and 21 of 26 were improved after hyperbaric oxygen therapy. We had concluded that hyperbaric oxygen therapy is an important component of a comprehensive plan for management of patients after radiation therapy for cancer in whom necrosis of the tissue occurs. I f the results o f our early study when hyperbaric oxygen was not used routinely
266
Letters to the editor
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 1996 are c o m p a r e d with our results w h e n hyperbaric oxygen was routinely used, 3 resolution in 15% versus 60% to 70% demonstrates superior results with the addition o f hyperbaric oxygen. The article by van M e r k e s t e y n et al. confirms our experience. REFERENCES
1. Epstein JB, Wong FLW, Stevenson-Moore P, Osteoradionecrosis: Clinical experience and a proposal for classification. J Oral Maxillofac Surg 1987;45:104-10. 2. Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg 1983;41:351-7. 3. McKenzie MR, Wong FLW, Epstein JB, Lepawsky M. Hyperbaric oxygen and postradiation osteonecrosis of the mandible. Oral Oncol, Eur J Cancer 1993;29B:201-7.
Joel Epstein, DMD, MSD Erik van der Meij, DDS Michael McKenzie, MD, FRCP(C) Frances Wong, BSc, MD, FRCP(C) Peter Stevenson-Moore, BDS, MSD, MRCD(C) B. C. Cancer Agency 600 W. 10th Avenue Vancouver, BC. CANADA V5Z 4E6
In Reply W e thank Dr. Epstein and his colleagues for their c o m m e n t s o n our article on the treatment of osteoradionecrosis of the m a n d i b l e and w e l c o m e the opportunity to discuss the m a n a g e m e n t of osteoradionecrosis. Dr. Epstein et al. are correct in their remark that in
fact the treatment of osteoradionecrosis with hyperbaric o x y g e n considers 27 of the 29 patients. However, we did clearly state this fact, and we included these patients because of the fact that in our view since the favorable results of hyperbaric oxygen have b e e n published, a t e n d e n c y to over-treatment with H B O has developed and to show that surgery and antibiotics m a y still be sufficient. W e agree with Dr. Epstein et al. that strict criteria should be used. That is the reason for not including c o n t i n u i t y of the m a n d i b l e as a criterium for resolution of osteoradionecrosis. Closed soft tissues, the absence of pain, and i m p r o v e d or stable radiographs are criteria for the resolution of osteoradionecrosis. The loss of continuity of the m a n d i b l e is an indication of the severity of the osteoradionecrosis and the reconstruction of c o n t i n u i t y (as frequently reported b y Dr. Marx) is the result of excellent patient m a n a g e m e n t and an indication of the possibilities of reconstructive surgery in the irradiated tissues w h e n c o m b i n e d with HBO, but not a criterium for resolution of necrosis. W e hope that reporting of series of patients with special reference to the loss of c o n t i n u i t y of the mandible after " r e s o l u t i o n " of osteoradionecrosis m a y lead to early recognition and less extensive treatment of this group of patients.
J.P.R. van Merkesteyn, DDS, PhD Department of Oral and Maxillofacial Surgery Academic Hospital Leiden Postbox 9600, 2300 RC Leiden The Netherlands
CALL FOR LETTERSTO THE EDITOR
A separate and distinct space for Letters to the Editor was established by Larry J. Peterson, editor in chief of ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY,AND ENDODONTICS
in his Editorial in the January 1993 issue. Dr. Peterson also encouraged brief reports on interesting observations and new developments to be submitted to appear in this letters section as well as Letters commenting on earlier published articles. Please submit your letters and brief reports for inclusion in this section. Information for authors for the Journal appears in this issue of ORALSURGERY,ORALMEDICINE,ORALPATHOLOGY,ORAL RADIOLOGY,AND ENDODONTICS. We look forward to hearing from you.
Letters to the editor
265
Volume 81, Number 3
In Reply We are grateful for the interest Dr. Dodson has shown in our article entitled, Relationship between fractures of the mandibular angle and the state of eruption of the lower third molar, and note his comments. His analysis of our data as presented in his table is flawed. H o w e v e r it does confirm a trend relating increased risk of angle fracture to depth of impaction; the only deviation being with our group classified with an impaction score of 6 and this could be attributable to the low numbers in this subset. The method of analysis we employed (Chi-squared test for linear trends in proportions) was one that is sensitive to trends and confirms our conclusions. Nevertheless it is obvious that such sensitivity, although of academic interest, is of little clinical value when compared with the influence the presence of a third molar tooth has on angle weakness, which both Dr. Dodson's study and our own have demonstrated. Nadim Safdar John G. M e e c h a n
Department of Oral Surgery The Dental School Newcastle upon Tyne, U.K.
Hyperbaric oxygen therapy Letter to the editor:
We welcome the addition to the literature of Dr. van Merkesteyn et al., Hyperbaric oxygen treatment of osteoradionecrosis of the mandible: Experience in 29 patients, that was recently published (ORAL SURG ORAL MED ORAL PATHOL 1995;80:12-6.). The purpose we have in submitting this letter is to clarify their reference to our previous studies and to enhance the discussion regarding management of necrosis of the jaw after radiation therapy and the value of hyperbaric oxygen therapy. Agreement on the criteria for assessing the clinical status of patients is needed. We have previously published a clinical scale to allow a staging of necrosis so that therapy can be chosen and reports of outcomes of therapy may be facilitated. 1 This clinical description allows an understanding of resolved cases with or without previous pathologic fracture and with or without continuity of the mandible being achieved, chronic nonprogressive exposure of bone with or without mandibular discontinuity, and active progressive and symptomatic necrosis. The difficulty in assessing different criteria for resolution of necrosis is evident upon reading of the
recent article by Dr. van Merkesteyn et al. In this article the authors concluded that 20 of 29 patients with necrosis were considered to be resolved after treatment. The authors in fact reported on 27 patients, as only 27 of the original 29 patients were treated with hyperbaric oxygen therapy. As their study was of hyperbaric oxygen treatment, the two patients who did not receive hyperbaric oxygen therapy should not be included in percentage outcomes of the cases that had been treated with hyperbaric oxygen therapy. Criteria for resolution included closure of soft tissues, no pain, and improvement or stable findings on radiographs. However, these findings were not described in detail within the article. If their treatment outcomes would have been assessed with more strict criteria that included maintenance of continuity of the mandible and closure of soft tissues as has been suggested by Marx, 2 the outcome of their therapy would be considerably worse. Indeed 13 patients experienced discontinuity of the mandible at referral; 2 patients showed healing after their treatments and five additional patients lost mandibular continuity during treatment. This indicates that 60% (16 of 27) of patients treated in their study population experienced discontinuity of the mandible at the end of the study period. The authors then compared the results of their study with the outcome of a treatment of a series of cases that we bad reported at a time when hyperbaric oxygen therapy was not a consistent part of the management approach at our institution.l In their review of our study they note that 15% of patients have resolution and 42% stabilized after clinical treatment; hyperbaric oxygen was part of management in two cases. In this study we also reported the results of episodes of clinical necrosis that showed 33% were resolved, 15% were improved, 42% were stable, and 9% were worse. We began regular institution of hyperbaric oxygen therapy in these patients as reported in 1993. 3 In this study, 26 patients were diagnosed and treated with hyperbaric oxygen therapy. All but eight patients received some form of surgical management. A median of 35 sessions of hyperbaric oxygen therapy was administered. The results of this study were that 18 of 26 patients achieved persistent mucosal and cutaneous coverage, 13 of 26 met strict criteria of resolution of the disease process, and 21 of 26 were improved after hyperbaric oxygen therapy. We had concluded that hyperbaric oxygen therapy is an important component of a comprehensive plan for management of patients after radiation therapy for cancer in whom necrosis of the tissue occurs. I f the results o f our early study when hyperbaric oxygen was not used routinely
266
Letters to the editor
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 1996 are c o m p a r e d with our results w h e n hyperbaric oxygen was routinely used, 3 resolution in 15% versus 60% to 70% demonstrates superior results with the addition o f hyperbaric oxygen. The article by van M e r k e s t e y n et al. confirms our experience. REFERENCES
1. Epstein JB, Wong FLW, Stevenson-Moore P, Osteoradionecrosis: Clinical experience and a proposal for classification. J Oral Maxillofac Surg 1987;45:104-10. 2. Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg 1983;41:351-7. 3. McKenzie MR, Wong FLW, Epstein JB, Lepawsky M. Hyperbaric oxygen and postradiation osteonecrosis of the mandible. Oral Oncol, Eur J Cancer 1993;29B:201-7.
Joel Epstein, DMD, MSD Erik van der Meij, DDS Michael McKenzie, MD, FRCP(C) Frances Wong, BSc, MD, FRCP(C) Peter Stevenson-Moore, BDS, MSD, MRCD(C) B. C. Cancer Agency 600 W. 10th Avenue Vancouver, BC. CANADA V5Z 4E6
In Reply W e thank Dr. Epstein and his colleagues for their c o m m e n t s o n our article on the treatment of osteoradionecrosis of the m a n d i b l e and w e l c o m e the opportunity to discuss the m a n a g e m e n t of osteoradionecrosis. Dr. Epstein et al. are correct in their remark that in
fact the treatment of osteoradionecrosis with hyperbaric o x y g e n considers 27 of the 29 patients. However, we did clearly state this fact, and we included these patients because of the fact that in our view since the favorable results of hyperbaric oxygen have b e e n published, a t e n d e n c y to over-treatment with H B O has developed and to show that surgery and antibiotics m a y still be sufficient. W e agree with Dr. Epstein et al. that strict criteria should be used. That is the reason for not including c o n t i n u i t y of the m a n d i b l e as a criterium for resolution of osteoradionecrosis. Closed soft tissues, the absence of pain, and i m p r o v e d or stable radiographs are criteria for the resolution of osteoradionecrosis. The loss of continuity of the m a n d i b l e is an indication of the severity of the osteoradionecrosis and the reconstruction of c o n t i n u i t y (as frequently reported b y Dr. Marx) is the result of excellent patient m a n a g e m e n t and an indication of the possibilities of reconstructive surgery in the irradiated tissues w h e n c o m b i n e d with HBO, but not a criterium for resolution of necrosis. W e hope that reporting of series of patients with special reference to the loss of c o n t i n u i t y of the mandible after " r e s o l u t i o n " of osteoradionecrosis m a y lead to early recognition and less extensive treatment of this group of patients.
J.P.R. van Merkesteyn, DDS, PhD Department of Oral and Maxillofacial Surgery Academic Hospital Leiden Postbox 9600, 2300 RC Leiden The Netherlands
CALL FOR LETTERSTO THE EDITOR
A separate and distinct space for Letters to the Editor was established by Larry J. Peterson, editor in chief of ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY,AND ENDODONTICS
in his Editorial in the January 1993 issue. Dr. Peterson also encouraged brief reports on interesting observations and new developments to be submitted to appear in this letters section as well as Letters commenting on earlier published articles. Please submit your letters and brief reports for inclusion in this section. Information for authors for the Journal appears in this issue of ORALSURGERY,ORALMEDICINE,ORALPATHOLOGY,ORAL RADIOLOGY,AND ENDODONTICS. We look forward to hearing from you.