Extracting in irradiated bone

An extraction in bone that has received a high radiation dose is a wound in tissue that has lost much of its capacity to repair itself, and the risk of osteoradionecrosis that follows it depends mostly on where the tooth is and how much radiation that site received: in the pooled observational evidence the irradiated mandible carries most of the cases, and higher mandibular dose, smoking and diabetes all raise the odds, though those figures come from heterogeneous, mostly retrospective studies under definitions that do not agree with each other. Hyperbaric oxygen before extraction was the standard for decades on the strength of a 1985 trial with a high osteoradionecrosis rate in its antibiotic arm; the HOPON randomised trial, in mandibles that had received more than 50 Gy, found osteoradionecrosis in 6.4% with hyperbaric oxygen and 5.7% without, on a confidence interval wide enough to be compatible with benefit as well as harm, and in a population that the trial's critics argue included lower-risk patients. The 2024 ISOO-MASCC-ASCO guideline describes hyperbaric oxygen for prevention and management as largely unjustified on limited evidence. Pooled rates after extraction with antibiotics, with pentoxifylline-tocopherol and with hyperbaric oxygen are all low and similar to each other, but they come mostly from observational studies, and a systematic review of the pentoxifylline-tocopherol prevention studies judged the evidence insufficient to recommend it. My own approach is antibiotics, an atraumatic extraction and primary closure, with no routine referral for prophylactic hyperbaric oxygen, and pentoxifylline-tocopherol left to the oncology team as their prescription; a multi-tooth lower-jaw case in a smoker or a diabetic is one I would rather not do, and if it has to be done, one tooth first and watch it heal.