I now have additional information from the surgeon's documentation: 2/21/24 all mucosa is soft and intact. Osteoradionecrosis was added as a problem 2/21/24 (surgeon's notes). Patient presents today for continued discussion surrounding dental rehabilitation, since his last appointment, he has had maxillary and mandibular dentures fabricated, he is not tolerating it much due to poor dentition. Denies any new pains or complaints. 1/29/24 Presents for healing evaluation. Reports good PO and no new symptoms. Denies voice changes, pain, ulcers, worsening ability to swallow. Good integration and mucosalization of reconstruction, no sign of dehiscence, no new growth or lesion, minimal available vestibule. 12/27/2022 - Bilateral composite resection of tongue, FOM, mandibular resection with radical neck dissection; L modified radical neck dissection; Tracheostomy; Left fibula free osteocutaneous flap; Left thigh STSG; Application of reconstruction bar to mandible; alveoloplasty; Application of wound vac; Dobhoff placement

Can we bring him in on an osteoradionecrosis diagnosis from his surgeon + poor dentition for ORN of the mandible? As opposed to prep for dental implants?

Sarah,

You have an very frustrating but unfortunately all to common clinical problem, where the UMHS recommends HBO for a clinical condition but CMS or commercial carriers say that they will not pay for that condition. The UHMS does indeed recommend prophylactic HBO for prevention of ORN in patients who have received "high" doses of radiation to the mandible (re. > 6000 cgy). And in the most current update to the UHMS HBO Indications manual (15th ed). Drs. Feldmeier and Gesell do mention dental implants as a potential cause of ORN (page 181).

With regards to your specific question as to HBO treatment, the answer is, it depends. For prophylactic ORN, you would need to information about how much and what type of radiation the patient had, when was the radiation given, how may fractions. Many HBO physicians have looked for other STRI that the patient may be experiencing and then treat the patient for the STRI, while prophylaxing for ORN. Examples of this would be if the patient had a history of head and neck radiation and needed a dental procedure, but was also experiencing dysphagia or xerostomia due to the radiation.

Given your new information from the surgeon, that the patient now has a diagnosis of ORN. You could document a discussion between your doctor and the surgeon as to how the diagnosis was made and the surgical plan. In that case you would be TREATING ORN, not doing HBO for prophylaxis and that requires different documentation to make the diagnosis. Finally, I would recommend you take a look at the UHMS Indications Manual, 15th ed, pages 174-184.

Hi, thank you so much for your response. As there is not evidence of exposed bone, the patient wouldn't fall into the Marx classification - so would ORN treatment be an acceptable diagnosis? Even following a conversation between doc and surgeon? Seems like STRI, while prophylaxing for ORN, confirming any additional symptoms, along with the poor dentition would be the most solid diagnosis to support. Thank you!

Sarah,

It is my understanding that for ORN, some amount of exposed bone is required to make the diagnosis but I would defer to your oral surgeon. And you are correct that IF the patient has STRI then you would certainly be on solid clinical ground to treat the STRI while you just happen to be prophylaxing for ORN.

Thank you for your insight!