title: Multimodality surgical and hyperbaric management of mandibular osteoradionecrosis.
abstract: OBJECTIVE
  To elucidate long-term outcomes in 65 consecutive patients meeting a uniform definition of mandibular osteoradionecrosis (ORN) treated with multimodality therapy including hyperbaric oxygen (HBO).
  
  
  METHODS
  Pretreatment, post-treatment and long-term follow-up of mandibular lesions with exposed bone were ranked by a systematic review of medical records and patient telephone calls. The ranking system was based on lesion diameter and number plus disease progression. Changes from pretreatment to post-treatment and follow-up were analyzed by Wilcoxon signed-rank tests. Improved wound survival, measured by time to relapse, defined as any less favorable rank after HBO treatment, was assessed by Kaplan-Meier analysis.
  
  
  RESULTS
  In all, 57 cases (88%) resolved or improved by lesion grade or progression and evolution criteria after HBO (p < 0.001). Four patients healed before surgery after HBO alone. Of 57 patients who experienced improvement, 41 had failed previous nonmultimodality therapy for 3 months and 26 for 6 months or more. A total of 43 patients were eligible for time-to-relapse survival analysis. Healing or improvement lasted a mean duration of 86.1 months (95% confidence interval [95% CI], 64.0-108.2) in nonsmokers (n = 20) vs. 15.8 months (95% CI, 8.4-23.2) in smokers (n = 14) versus 24.2 months (95% CI, 15.2-33.2) in patients with recurrent cancer (n = 9) (p = 0.002 by the log-rank method).
  
  
  CONCLUSIONS
  Multimodality therapy using HBO is effective for ORN when less intensive therapies have failed. Although the healing rate in similarly affected patients not treated with HBO is unknown, the improvements seen with peri-operative HBO were durable provided that the patients remained cancer free and abstained from smoking.
authors.affiliation: Department of Anesthesiology, Center for Hyperbaric Medicine and Environmental Physiology, Duke University Medical Center, Durham, NC, USA. freib002@mc.duke.edu
authors.forename: John J
authors.initials: JJ
authors.lastname: Freiberger
authors.forename: David S
authors.initials: DS
authors.lastname: Yoo
authors.forename: Guy
authors.initials: G
authors.lastname: de Lisle Dear
authors.forename: Thomas A
authors.initials: TA
authors.lastname: McGraw
authors.forename: George H
authors.initials: GH
authors.lastname: Blakey
authors.forename: Rebecca
authors.initials: R
authors.lastname: Padilla Burgos
authors.forename: Kevin
authors.initials: K
authors.lastname: Kraft
authors.forename: John W
authors.initials: JW
authors.lastname: Nelson
authors.forename: Richard E
authors.initials: RE
authors.lastname: Moon
authors.forename: Claude A
authors.initials: CA
authors.lastname: Piantadosi