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X-Ray Irradiation and Osteonecrosis of the Jaws
THE J O U R N A L AMERICAN DENTAL ASSOCIATION o f the
V o l. 28
D E C E M B E R 1941
N o. 12
X-RAY IRRADIATION AND OSTEONECROSIS OF THE JAW S B y F r a n k F . K a n t h a k , M .D ., D .D .S ., C h ica g o , 111 .
T
H E adverse effect o f h e a v y x-ra y skin effect and afford n o histologic ev i or radium therapy on osseous dence o f cellular chan ge in the bone. C lu zet, in 1910, exposed th e bones of rabbits structure is fu lly appreciated b y radiologists and those treating tum ors and o f dogs to x-rays b efore and a fter fra c tures. A lth o u gh n o erythem a o f the the head and neck. T h a t such irrad ia tion presents a distinct contraindication skin was produced b y the dosage used, to the extraction o f teeth or other oral the form ation o f callus w as absent for from tw enty-one to thirty-fou r days in surgical procedures is not fu lly appreci dogs and fo r eighteen days in rabbits. ated. T h is com m unication w ill review H ealing, although grea tly delayed, o c the effects o f irradiation on osseous struc curred w ith the form ation o f a hard c al ture and report several illustrative cases involvin g the jaws. lus on the side o f the bones opposite the irradiated area. R e ga u d (1922) first E w in g (1926) has review ed the re called attention to the g rea t susceptibil actions o f bone to irradiation , a subject that deserves fu rth er investigation. ity o f the jaw s to necrosis and infection du rin g the treatm ent o f intraoral car Perthes, in 1903, shortly a fte r the dis cinom a. H e noted b o n y necrosis beneath covery o f the roentgen rays, carried out uninjured skin and concluded that bone experim ents to determ ine the effects o f is m ore susceptible to irradiation than is these rays on livin g tissue. T h e right skin. I t is evident, as W atson and S car w ing o f i-d ay-old chickens w as exposed borough (1938) po in t out, that h eavy to roentgen rays, and, a t th e end o f tw elve days, it w as fou n d th a t the w ing external irradiation causes changes in the bone and periosteum w h ich dim in so treated was sm aller th an the one on the opposite side and its feathers w ere ish their pow er o f resistance to infection and thus increase their susceptibility to m ore sparse. In 1905, R eca m ier and T rib on d eau showed th a t grow th o f bone infection and traum a. T h e periosteum is apparently v e ry susceptible to irradiation. in chickens could be inh ibited b y a dose A fte r ad equ ate therapeutic doses of o f roentgen rays so sm all as to h ave no Jour. A.D.A., Vol. 28, December 194.1
1925
1926
T
he
J ournal
of the
A m e r ic a n D
x-rays, sw elling and thickenin g o f the periosteum occur and it can be stripped easily fro m the bone. H istologic exam ination o f irradiated periosteum indicates th a t the inn er surface is th ick ly hyalinized. T h e layer o f osteoblasts u sually fou n d in the inn er lay er o f the perios teum m a y b e absent. E w in g has shown histologically th at irradiated bone seems to present w id en in g and irregu larity o f lacun ae and can alicu li and a p artial loss o f lam ellar structure. T h is indicates that the bone cells themselves are readily killed b y irradiation and thus the entire bone suffers devitalization and alteration. In ad dition to these effects, there is con siderable reaction o f the vascu lar supply o f the bone. T h e vessels tend to becom e thickened and are finally obliterated. In
Fig. 1.— Mandible irradiated for carcinoma of tonsil. Marked mottling of the bone with areas of increased and decreased density is evident. Roots of the lower first molar are being exfoliated. These bone changes may be considered as aseptic necrosis due to the de crease in the normal vascularity of the man dible.
addition to the d eath of bone cells noted above, an aseptic type o f necrosis o f the bone occurs. (F ig. 1.) T h is reaction has m ost freq u en tly been described in the fem urs, follow in g irradiation fo r the treatm ent o f carcinom a o f the ovary, etc. T h e necrosis o f the bone is p ro duced en tirely on a circu lato ry basis w ith ou t an y com ponent o f infection, and m a y be so severe as to result in p a th o logic fractu re of the fem ur. T h a t these adverse effects o f irrad ia
ental
A s s o c ia t io n
tion o f oral tum ors are a frequ en t enough com plication to w a rran t m ore attention is indicated b y the report o f W atson and Scarborough from the M em orial H ospital o f N ew Y o rk C ity. O f 1,819 patients w ith intraoral ca rci n om a treated from 1930 to 1937, 235, or 13 per cent, developed osteoradio necrosis o f the jaw s. Salm an and K a u f m an (19 3 7) h ave also published a report on this subject, calling attention to the association o f necrosis o f the m andible w ith x -ra y irradiation. T h ree definite factors seem to be co n d u cive to osteoradionecrosis: irradiation,
Fig. 2.— Left side of mandible, showing pathologic fracture in bicuspid region and marked mottling and moth-eaten appearance of bone posterior to the fracture.
in fection and traum a. As ind icated in the previous section, irradiation o f osseous tissue tends not o n ly to destroy th e norm al resistance o f the tissue to in fection and its response to healing, bu t also to alter the entire process o f healing. In fectio n is induced b y po or oral h y giene, general lack o f care o f the m outh and the retention o f carious and brokendow n teeth. T ra u m a is usu ally ad ded to this b u rd en b y the sim ple extraction of a tooth. A fte r the extraction, the socket
K
anthak—
X -R
ay
I r r a d ia t io n
shows no tenden cy to heal and the ad ja cen t soft tissues seem to m elt aw ay, leavin g a large portion o f the bone e x posed to the m outh and denuded o f all soft tissue covering. Suppuration is p ro fuse and continuous. T h e patien t com plains of continuous dull, steady pain and m arked trismus. B ecause o f the m arked reduction in h ealin g o f the in volved bone, little or no ten d en cy fo r
Fig. 3.— Appearance of left side of man dible after removal of sequestrum with as little trauma to adjacent tissues as possible.
Fig. 4.— Mandible exposed in mouth and on face.
sequestration is evident fo r some tim e. A fte r a lon g but variable interval, usu ally m ore than six months, a line o f sep aration of the dead bone m a y becom e apparent on x-ra y exam ination or a pathologic fractu re m ay develop. A t this stage, sequestrectom y m a y b e indicated, consisting in the rem oval o f all bone ob
and
O
s t e o n e c r o s is
1927
viously dead, w ith as little disturbance o f the soft tissues as possible. U su ally, the sequestrum consists in a full-thickness section o f the ja w , and little ten d en cy is noted fo r lon gitu d inal separation o f the dead bone, w h ich is exfoliated en masse. A fte r sequestrectom y o f the m andible destroying the con tin u ity o f the ja w , it m a y be advisable to h old the ja w in cor rect occlusion w ith elastic traction until
Fig. 5.— Sequestration of fragment of man dible, 3 inches in length, from molar region to sigmoid notch.
Fig. 6.— Defect left by removal of seques trum.
a certain am ount o f h ealing o f the soft tissue ensues. T h is w ill reduce deform ity and fu n ctional disability. Pain and tris mus are ord inarily rea d ily relieved fo llo w in g the rem oval o f n ecrotic bone. Suppuration in reduced degree continues until all dead bone has been cast off and soft tissue h ealin g is com plete. I t is im portant to recognize that although
1928
T
he
J ournal
of the
A m e r ic a n D
osteoradionecrosis o f the jaw s occurs w ith ou t the addition o f extraction traum a, the rem oval o f teeth has been follow ed freq u en tly enough b y extensive necrosis to m ake it a ve ry hazardous un dertaking in the patien t w ho has re ceived irradiation. Because o f the relatively h igh in ci dence o f osteoradionecrosis o f the jaw s follow in g x -ra y treatm ent o f neoplasms o f the oral ca v ity and contiguous struc tures, it is evid en t th a t all infected teeth or questionable teeth should be extracted, the rem ain ing teeth cleaned and the m outh p u t in as good condition as pos sible, prior to treatm ent. Since the e f fects o f irradiation o f the jaw s lasts fo r several years or an indeterm inate tim e,
Fig. 7.— Closure of defect by sliding flaps of tissue from margins of wound.
it is o ften wise to rem ove all teeth prior to irradiation to elim inate the possibility o f extraction traum a subsequent to ir radiation. T h e feelin g am ong rad io therapists th a t the fortu n ate patien t w ith oral can cer is the edentulous patien t is p revalen t fo r these reasons. In addition, rem oval o f the fro n t teeth allow s the radiotherapist to utilize intraoral x-ra y radiation, w h ich is ad vantageous in the treatm ent o f certain cases o f intraoral carcinom a, as that o f the floor o f the m outh. F o r the person w h o has received rad iation th erapy and has subsequently d eveloped toothache or pain abou t the teeth and gums, on ly conservative m eas
ental
A
s s o c ia t io n
ures should be used to treat these p a tients until such tim e has elapsed since irradiation that the rem oval o f teeth m a y be considered safe. H ow ever, as stated previously, this is such an in determ inate period th at u npleasant den tal sequelae o f caries or periodontal disease m ay be difficult to control. r e p o r t
o f
c a s e s
C a s e i.— History.— A man, aged 57, was referred by his physician with the following history: In March 1939, a new growth was discovered on the left anterior tonsillar pil lar which, on biopsy, proved to be a squa mous-cell carcinoma. The patient received x-ray radiation in an unknown amount, di rected to the left side of the neck. In M ay 1940, an area of leukoplakia and a continua tion of the lesion were noted on the left anterior pillar, and 10 radon implants were made in the anterior pillar at the base of the tongue to supply interstitial radiation to the lesion. One month later, complaining of a toothache, the patient visited his dentist, who extracted the lower left first molar. A l most immediately after the extraction, the patient complained of increasing pain and soreness. The soft tissue overlying the man dible sloughed away, leaving the bare bone exposed to the mouth. Profuse suppuration and marked trismus ensued, permitting only a one-quarter inch movement of the jaws. Exam ination .— When first seen, the patient was miserable. Continuous dull pain requir ing sedatives was present, trismus was marked and suppuration was constant. The patient had lost 18 pounds. The soft tissues of the mouth were very sensitive to palpa tion. It was noted that a portion of the mandible measuring about i-| inches in length was lying exposed to the oral cavity. (Fig. 2.) A soft, fluctuant swelling was pres ent in the neck anteriorly from the sterno cleidomastoid muscle over the diagastric triangle. An x-ray picture revealed a path ologic fracture of the mandible in the bi cuspid region with a markedly moth-eaten appearance of the bone posteriorly almost to the sigmoid notch. Diagnosis .— T he diagnosis was osteoradio necrosis of the mandible, with cervical ab scess. Treatm ent .— Under avertin anesthesia S u p -
K
anthak—
X -R
ay
I r r a d ia t io n
plemented by deep procaine block, the jaws were pried open and the necrotic portion of the mandible was removed. This represented a full-thickness section of the jaw about 1J inches in length. (Fig. 3.) A ll obviously dead or diseased bone was removed with a rongeur. Very little bleeding followed. The cervical abscess was incised and drained of about 15 cc. of foul yellow pus. Fenestrated rubber tubes were inserted and a bandage was placed. Postoperatively, the jaws were held in optimum position with elastic trac tion until healing took place. O utcom e .— Pain and discomfort were im mediately relieved, trismus was reduced and, for the first time in months, the patient could eat without suffering. C ase 2.— History .— A colored woman, aged 39, had trismus, pain and swelling of the left mandible and suppuration into the mouth. In 1937, the left submaxillary salivary gland was removed (diagnosis: car cinoma of salivary gland) and, after this operation, the patient received an unknown amount of x-ray radiation on that side of the neck. In January 1939, about fifteen months after operation, she had pain in the lower left second molar and her dentist ex tracted the tooth. Three days after the ex traction, the patient again visited her den tist, who treated her for several weeks thereafter for “ dry socket.” This wound showed no disposition to heal and the man dible was curetted. Thereafter, the soft tis sues overlying the mandible both intraorally and extraorally sloughed, leaving the angle of the mandible and a portion of the body and ascending ramus exposed. (Fig. 4.) Exam ination .— The patient complained of almost constant severe pain in the jaw, and there was marked trismus, with suppuration. She was obtaining relief from pain by the use of morphine sulfate, and, because it was feared that she was developing an addiction to morphine, other non-narcotic anodynes were prescribed for pain relief. Operation and O utcom e .— Five months
and
O
s t e o n e c r o s is
1929
after the abortive curettage took place, the mandible from the bicuspid region to the sigmoid notch was removed as a seques trum. (Figs. 5 and 6.) The pain and tris mus were almost immediately relieved. The soft tissue defect remaining on the face was closed by sliding flaps of tissue and a satis factory result was obtained after several cor rective procedures. The lower jaw was held in position by elastic traction for several months and the traction then discontinued. A t the present time, the patient is entirely free of disease and has a well-functioning mandible. SU M M A RY
T h e adverse effects o f x-ra y irradiation of bone consist essentially in a reduction o f vita lity and circulation o f the osseous tissue and the periosteum , rendering the jaw s m ore susceptible to extensive in fe c tion and necrosis. T h e conditions re sponsible fo r necrosis o f the jaw s are irradiation, infection and traum a. T h e tw o cases cited illustrate the hazards o f e xtractin g teeth in patients w ho h ave received extensive x-ra y or radium therapy directed to the fa ce or jaw s fo r the treatm ent o f carcinom a. BIBLIO G R A PH Y E w in g ,
Ja m e s :
Radiation Osteitis.
A cta
R a d iol., 6:399, 1926. R e g a u d , C .: Sur la Necrose des Os Atteints par un Processus Cancereux et Traites par les Radiations. C om pte rend. Soc. de biol., 87:427, 629, 1922. S a l m a n , I r v i n g , and K a u f m a n , W i l l i a m : Necrosis of Mandible Associated with Radia tion Therapy. Internat. J. O rthodontia, : 94, January 1937. W a t s o n , W . L., and S c a r b o r o u g h , J. E .: Osteoradionecrosis in Intraoral Cancer. Am . J. Roentgenol., 4 0 : 524 , October 1938.
23
808 South Wood Street.
V o l. 28
D E C E M B E R 1941
N o. 12
X-RAY IRRADIATION AND OSTEONECROSIS OF THE JAW S B y F r a n k F . K a n t h a k , M .D ., D .D .S ., C h ica g o , 111 .
T
H E adverse effect o f h e a v y x-ra y skin effect and afford n o histologic ev i or radium therapy on osseous dence o f cellular chan ge in the bone. C lu zet, in 1910, exposed th e bones of rabbits structure is fu lly appreciated b y radiologists and those treating tum ors and o f dogs to x-rays b efore and a fter fra c tures. A lth o u gh n o erythem a o f the the head and neck. T h a t such irrad ia tion presents a distinct contraindication skin was produced b y the dosage used, to the extraction o f teeth or other oral the form ation o f callus w as absent for from tw enty-one to thirty-fou r days in surgical procedures is not fu lly appreci dogs and fo r eighteen days in rabbits. ated. T h is com m unication w ill review H ealing, although grea tly delayed, o c the effects o f irradiation on osseous struc curred w ith the form ation o f a hard c al ture and report several illustrative cases involvin g the jaws. lus on the side o f the bones opposite the irradiated area. R e ga u d (1922) first E w in g (1926) has review ed the re called attention to the g rea t susceptibil actions o f bone to irradiation , a subject that deserves fu rth er investigation. ity o f the jaw s to necrosis and infection du rin g the treatm ent o f intraoral car Perthes, in 1903, shortly a fte r the dis cinom a. H e noted b o n y necrosis beneath covery o f the roentgen rays, carried out uninjured skin and concluded that bone experim ents to determ ine the effects o f is m ore susceptible to irradiation than is these rays on livin g tissue. T h e right skin. I t is evident, as W atson and S car w ing o f i-d ay-old chickens w as exposed borough (1938) po in t out, that h eavy to roentgen rays, and, a t th e end o f tw elve days, it w as fou n d th a t the w ing external irradiation causes changes in the bone and periosteum w h ich dim in so treated was sm aller th an the one on the opposite side and its feathers w ere ish their pow er o f resistance to infection and thus increase their susceptibility to m ore sparse. In 1905, R eca m ier and T rib on d eau showed th a t grow th o f bone infection and traum a. T h e periosteum is apparently v e ry susceptible to irradiation. in chickens could be inh ibited b y a dose A fte r ad equ ate therapeutic doses of o f roentgen rays so sm all as to h ave no Jour. A.D.A., Vol. 28, December 194.1
1925
1926
T
he
J ournal
of the
A m e r ic a n D
x-rays, sw elling and thickenin g o f the periosteum occur and it can be stripped easily fro m the bone. H istologic exam ination o f irradiated periosteum indicates th a t the inn er surface is th ick ly hyalinized. T h e layer o f osteoblasts u sually fou n d in the inn er lay er o f the perios teum m a y b e absent. E w in g has shown histologically th at irradiated bone seems to present w id en in g and irregu larity o f lacun ae and can alicu li and a p artial loss o f lam ellar structure. T h is indicates that the bone cells themselves are readily killed b y irradiation and thus the entire bone suffers devitalization and alteration. In ad dition to these effects, there is con siderable reaction o f the vascu lar supply o f the bone. T h e vessels tend to becom e thickened and are finally obliterated. In
Fig. 1.— Mandible irradiated for carcinoma of tonsil. Marked mottling of the bone with areas of increased and decreased density is evident. Roots of the lower first molar are being exfoliated. These bone changes may be considered as aseptic necrosis due to the de crease in the normal vascularity of the man dible.
addition to the d eath of bone cells noted above, an aseptic type o f necrosis o f the bone occurs. (F ig. 1.) T h is reaction has m ost freq u en tly been described in the fem urs, follow in g irradiation fo r the treatm ent o f carcinom a o f the ovary, etc. T h e necrosis o f the bone is p ro duced en tirely on a circu lato ry basis w ith ou t an y com ponent o f infection, and m a y be so severe as to result in p a th o logic fractu re of the fem ur. T h a t these adverse effects o f irrad ia
ental
A s s o c ia t io n
tion o f oral tum ors are a frequ en t enough com plication to w a rran t m ore attention is indicated b y the report o f W atson and Scarborough from the M em orial H ospital o f N ew Y o rk C ity. O f 1,819 patients w ith intraoral ca rci n om a treated from 1930 to 1937, 235, or 13 per cent, developed osteoradio necrosis o f the jaw s. Salm an and K a u f m an (19 3 7) h ave also published a report on this subject, calling attention to the association o f necrosis o f the m andible w ith x -ra y irradiation. T h ree definite factors seem to be co n d u cive to osteoradionecrosis: irradiation,
Fig. 2.— Left side of mandible, showing pathologic fracture in bicuspid region and marked mottling and moth-eaten appearance of bone posterior to the fracture.
in fection and traum a. As ind icated in the previous section, irradiation o f osseous tissue tends not o n ly to destroy th e norm al resistance o f the tissue to in fection and its response to healing, bu t also to alter the entire process o f healing. In fectio n is induced b y po or oral h y giene, general lack o f care o f the m outh and the retention o f carious and brokendow n teeth. T ra u m a is usu ally ad ded to this b u rd en b y the sim ple extraction of a tooth. A fte r the extraction, the socket
K
anthak—
X -R
ay
I r r a d ia t io n
shows no tenden cy to heal and the ad ja cen t soft tissues seem to m elt aw ay, leavin g a large portion o f the bone e x posed to the m outh and denuded o f all soft tissue covering. Suppuration is p ro fuse and continuous. T h e patien t com plains of continuous dull, steady pain and m arked trismus. B ecause o f the m arked reduction in h ealin g o f the in volved bone, little or no ten d en cy fo r
Fig. 3.— Appearance of left side of man dible after removal of sequestrum with as little trauma to adjacent tissues as possible.
Fig. 4.— Mandible exposed in mouth and on face.
sequestration is evident fo r some tim e. A fte r a lon g but variable interval, usu ally m ore than six months, a line o f sep aration of the dead bone m a y becom e apparent on x-ra y exam ination or a pathologic fractu re m ay develop. A t this stage, sequestrectom y m a y b e indicated, consisting in the rem oval o f all bone ob
and
O
s t e o n e c r o s is
1927
viously dead, w ith as little disturbance o f the soft tissues as possible. U su ally, the sequestrum consists in a full-thickness section o f the ja w , and little ten d en cy is noted fo r lon gitu d inal separation o f the dead bone, w h ich is exfoliated en masse. A fte r sequestrectom y o f the m andible destroying the con tin u ity o f the ja w , it m a y be advisable to h old the ja w in cor rect occlusion w ith elastic traction until
Fig. 5.— Sequestration of fragment of man dible, 3 inches in length, from molar region to sigmoid notch.
Fig. 6.— Defect left by removal of seques trum.
a certain am ount o f h ealing o f the soft tissue ensues. T h is w ill reduce deform ity and fu n ctional disability. Pain and tris mus are ord inarily rea d ily relieved fo llo w in g the rem oval o f n ecrotic bone. Suppuration in reduced degree continues until all dead bone has been cast off and soft tissue h ealin g is com plete. I t is im portant to recognize that although
1928
T
he
J ournal
of the
A m e r ic a n D
osteoradionecrosis o f the jaw s occurs w ith ou t the addition o f extraction traum a, the rem oval o f teeth has been follow ed freq u en tly enough b y extensive necrosis to m ake it a ve ry hazardous un dertaking in the patien t w ho has re ceived irradiation. Because o f the relatively h igh in ci dence o f osteoradionecrosis o f the jaw s follow in g x -ra y treatm ent o f neoplasms o f the oral ca v ity and contiguous struc tures, it is evid en t th a t all infected teeth or questionable teeth should be extracted, the rem ain ing teeth cleaned and the m outh p u t in as good condition as pos sible, prior to treatm ent. Since the e f fects o f irradiation o f the jaw s lasts fo r several years or an indeterm inate tim e,
Fig. 7.— Closure of defect by sliding flaps of tissue from margins of wound.
it is o ften wise to rem ove all teeth prior to irradiation to elim inate the possibility o f extraction traum a subsequent to ir radiation. T h e feelin g am ong rad io therapists th a t the fortu n ate patien t w ith oral can cer is the edentulous patien t is p revalen t fo r these reasons. In addition, rem oval o f the fro n t teeth allow s the radiotherapist to utilize intraoral x-ra y radiation, w h ich is ad vantageous in the treatm ent o f certain cases o f intraoral carcinom a, as that o f the floor o f the m outh. F o r the person w h o has received rad iation th erapy and has subsequently d eveloped toothache or pain abou t the teeth and gums, on ly conservative m eas
ental
A
s s o c ia t io n
ures should be used to treat these p a tients until such tim e has elapsed since irradiation that the rem oval o f teeth m a y be considered safe. H ow ever, as stated previously, this is such an in determ inate period th at u npleasant den tal sequelae o f caries or periodontal disease m ay be difficult to control. r e p o r t
o f
c a s e s
C a s e i.— History.— A man, aged 57, was referred by his physician with the following history: In March 1939, a new growth was discovered on the left anterior tonsillar pil lar which, on biopsy, proved to be a squa mous-cell carcinoma. The patient received x-ray radiation in an unknown amount, di rected to the left side of the neck. In M ay 1940, an area of leukoplakia and a continua tion of the lesion were noted on the left anterior pillar, and 10 radon implants were made in the anterior pillar at the base of the tongue to supply interstitial radiation to the lesion. One month later, complaining of a toothache, the patient visited his dentist, who extracted the lower left first molar. A l most immediately after the extraction, the patient complained of increasing pain and soreness. The soft tissue overlying the man dible sloughed away, leaving the bare bone exposed to the mouth. Profuse suppuration and marked trismus ensued, permitting only a one-quarter inch movement of the jaws. Exam ination .— When first seen, the patient was miserable. Continuous dull pain requir ing sedatives was present, trismus was marked and suppuration was constant. The patient had lost 18 pounds. The soft tissues of the mouth were very sensitive to palpa tion. It was noted that a portion of the mandible measuring about i-| inches in length was lying exposed to the oral cavity. (Fig. 2.) A soft, fluctuant swelling was pres ent in the neck anteriorly from the sterno cleidomastoid muscle over the diagastric triangle. An x-ray picture revealed a path ologic fracture of the mandible in the bi cuspid region with a markedly moth-eaten appearance of the bone posteriorly almost to the sigmoid notch. Diagnosis .— T he diagnosis was osteoradio necrosis of the mandible, with cervical ab scess. Treatm ent .— Under avertin anesthesia S u p -
K
anthak—
X -R
ay
I r r a d ia t io n
plemented by deep procaine block, the jaws were pried open and the necrotic portion of the mandible was removed. This represented a full-thickness section of the jaw about 1J inches in length. (Fig. 3.) A ll obviously dead or diseased bone was removed with a rongeur. Very little bleeding followed. The cervical abscess was incised and drained of about 15 cc. of foul yellow pus. Fenestrated rubber tubes were inserted and a bandage was placed. Postoperatively, the jaws were held in optimum position with elastic trac tion until healing took place. O utcom e .— Pain and discomfort were im mediately relieved, trismus was reduced and, for the first time in months, the patient could eat without suffering. C ase 2.— History .— A colored woman, aged 39, had trismus, pain and swelling of the left mandible and suppuration into the mouth. In 1937, the left submaxillary salivary gland was removed (diagnosis: car cinoma of salivary gland) and, after this operation, the patient received an unknown amount of x-ray radiation on that side of the neck. In January 1939, about fifteen months after operation, she had pain in the lower left second molar and her dentist ex tracted the tooth. Three days after the ex traction, the patient again visited her den tist, who treated her for several weeks thereafter for “ dry socket.” This wound showed no disposition to heal and the man dible was curetted. Thereafter, the soft tis sues overlying the mandible both intraorally and extraorally sloughed, leaving the angle of the mandible and a portion of the body and ascending ramus exposed. (Fig. 4.) Exam ination .— The patient complained of almost constant severe pain in the jaw, and there was marked trismus, with suppuration. She was obtaining relief from pain by the use of morphine sulfate, and, because it was feared that she was developing an addiction to morphine, other non-narcotic anodynes were prescribed for pain relief. Operation and O utcom e .— Five months
and
O
s t e o n e c r o s is
1929
after the abortive curettage took place, the mandible from the bicuspid region to the sigmoid notch was removed as a seques trum. (Figs. 5 and 6.) The pain and tris mus were almost immediately relieved. The soft tissue defect remaining on the face was closed by sliding flaps of tissue and a satis factory result was obtained after several cor rective procedures. The lower jaw was held in position by elastic traction for several months and the traction then discontinued. A t the present time, the patient is entirely free of disease and has a well-functioning mandible. SU M M A RY
T h e adverse effects o f x-ra y irradiation of bone consist essentially in a reduction o f vita lity and circulation o f the osseous tissue and the periosteum , rendering the jaw s m ore susceptible to extensive in fe c tion and necrosis. T h e conditions re sponsible fo r necrosis o f the jaw s are irradiation, infection and traum a. T h e tw o cases cited illustrate the hazards o f e xtractin g teeth in patients w ho h ave received extensive x-ra y or radium therapy directed to the fa ce or jaw s fo r the treatm ent o f carcinom a. BIBLIO G R A PH Y E w in g ,
Ja m e s :
Radiation Osteitis.
A cta
R a d iol., 6:399, 1926. R e g a u d , C .: Sur la Necrose des Os Atteints par un Processus Cancereux et Traites par les Radiations. C om pte rend. Soc. de biol., 87:427, 629, 1922. S a l m a n , I r v i n g , and K a u f m a n , W i l l i a m : Necrosis of Mandible Associated with Radia tion Therapy. Internat. J. O rthodontia, : 94, January 1937. W a t s o n , W . L., and S c a r b o r o u g h , J. E .: Osteoradionecrosis in Intraoral Cancer. Am . J. Roentgenol., 4 0 : 524 , October 1938.
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