CJ Henley, DMD, PA / San Marco, Jacksonville, Florida
Osteoradionecrosis of the jaw (ORN) and dental care in Jacksonville, FL.
Radiation changes the jaw for life. Your dental care should account for that.
Osteoradionecrosis is jawbone damaged by radiation that breaks down and doesn’t heal the way healthy bone does. At our San Marco office in Jacksonville, Dr. Henley helps head and neck cancer survivors lower that risk: before radiation, during it, and every time a tooth needs work afterward. He works alongside your oncology team, not in place of it.
- 8%of 2,732 patients treated with modern IMRT developed ORN in one large study2
- 50 Gyor more to the jaw is the dose at which guidelines consider ORN a risk1
- 2 weeksbetween a needed extraction and the start of radiation, when that doesn’t delay cancer care1
- Lifelongis how long the risk lasts in bone that received a high dose1
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Osteoradionecrosis of the jaw
What osteoradionecrosis is.
Osteoradionecrosis (ORN) is death of jawbone in an area that received radiation for head and neck cancer. Radiation damages the small blood vessels and bone cells, so the bone has less ability to heal. It can show up as exposed bone in the mouth, as changes on an X-ray or scan, or both. It can appear months or many years after treatment.
How the definition has changed
For decades, ORN was usually defined as irradiated bone that stays exposed and fails to heal for at least three months, and many articles still describe it that way.7 The 2024 ISOO-MASCC-ASCO guideline broadened it. ORN is now described as a lytic or mixed sclerotic bone lesion on imaging, and/or bone that is visibly exposed or can be probed through a gum pocket or fistula, in a site that received therapeutic head and neck radiation.1 There’s no waiting period, and early changes seen only on imaging count.
A tumor that comes back can look like ORN. Your oncology team decides whether a biopsy or imaging is needed to tell the difference. A biopsy is the only way to know for certain whether cancer is present.
How common is ORN
Less common than it used to be, but not rare.
Modern radiation techniques such as IMRT aim the dose more precisely, and recent studies report ORN in roughly 3% to 8% of patients. The number depends on tumor site, jaw dose, dental health, smoking, and how ORN was defined.
About 8% in a large cohort
At one major cancer center, 219 of 2,732 consecutive patients treated with curative IMRT developed ORN. Higher-risk patients developed it at 12.7%, lower-risk patients at 3.1%.2
About 3% in a pooled review
A meta-analysis of 875 patients treated with IMRT found ORN in 3.2%, about half of it linked to extractions. On average ORN appears more than two years after treatment.3,7
ORN risk factors
What raises the risk.
The biggest factor is how much radiation the bone received. Guidelines consider jaw doses of 50 Gy or more as at risk, and poor oral hygiene, dental surgery in the field, and tobacco add to it. The lower jaw is affected far more often than the upper jaw.
- Dose to the jaw. Bone receiving 50 Gy or more is considered at risk.1 In one large study, a dose of 60 Gy or more was among the strongest predictors.2
- Tumor site. Cancers of the mouth and oropharynx (tonsil and base of tongue) put more of the jaw in the high-dose area.2
- Lower jaw more than upper. The lower jaw is involved far more often, in part because its bone is denser with a more limited blood supply. Extractions in the back of the lower jaw are a well-known trigger.7
- Extractions and dental surgery in the field. Removing a tooth from high-dose bone is the classic trigger.1,7
- Gum disease and poor oral health. Advanced periodontal disease was an independent risk factor in the large cohort.2 Decay that leads to later extractions adds risk too.7
- Smoking and tobacco. Current or former smoking raised risk.1,2
- Timing. The risk doesn’t fade with time. An extraction ten years out needs the same care as one done the first year.1
Osteoradionecrosis symptoms
Signs to watch for after radiation.
The most common sign is a patch of yellow-white or gray bone showing through the gums that doesn’t close. Pain, swelling, lip or chin numbness, drainage, and fracture can follow. Some early ORN causes no symptoms and is found only on X-rays or scans.
Exposed bone
A rough, hard area in the gums, often where a tooth was removed or a denture rubs. It may not hurt at first.
Pain or swelling
A dull ache in the jaw, tenderness, or swelling that comes and goes. Infection can make it worse.
Numbness
A numb or heavy feeling in the lower lip or chin can mean the bone around the nerve is involved.
Drainage, fistula, or fracture
Pus, a bad taste, or a small opening on the gum or skin that keeps draining. Advanced ORN can weaken the jaw enough to break.7 A stiff jaw alone may be radiation-induced trismus instead.
Preventing ORN in Jacksonville
Prevention starts before the first radiation treatment.
Prevention matters more than any treatment. That means a dental exam before radiation, removing teeth with a poor outlook in the high-dose area about two weeks before treatment when time allows, daily prescription fluoride for life, and keeping teeth healthy enough that extractions are rarely needed afterward.
Before radiation
- A full dental assessment. The 2024 guideline recommends it before therapeutic radiation, both to find teeth that could cause trouble later and to teach you how to protect your mouth.1 See our pre-radiation dental exam page.
- Removing hopeless teeth in the field. Teeth with a poor prognosis, such as those with moderate to severe gum disease, are removed, ideally at least two weeks before radiation. That wait shouldn’t hold up treatment for a fast-growing tumor.1
After radiation
- Daily prescription fluoride. If radiation reduces your saliva, fluoride every day lowers decay, which lowers the chance of a future extraction.1,6 Custom fluoride trays make that easier.
- Saving teeth instead of removing them. In high-dose areas, a root canal, crown, or filling is preferred over extraction whenever it’s reasonable.1
- Not smoking. Tobacco is a risk factor you can change.1
Dental care after head and neck radiation
What to do if you need dental work after radiation.
Tell your dentist about your radiation before anything is done. Cleanings, fillings, crowns, and root canals are generally fine. Extractions, implants, and gum surgery in high-dose bone need a plan built around your radiation dose, with your care team involved.
Get your radiation summary.
Ask your radiation oncologist’s office for the treatment summary and, if possible, the dose to the mandible and maxilla. The guideline recommends reviewing that plan before dental treatment is finalized.1
Look for a way to keep the tooth.
A broken or decayed tooth can often be filled, crowned, or treated with a root canal. Implants in high-risk bone are avoided unless there’s no other option.1
If extraction is unavoidable, plan it carefully.
The guideline suggests your team consider antibiotics before and after, and, for cancer-free patients, pentoxifylline with vitamin E around the procedure. Both are weak recommendations based on limited evidence.1 Some cases belong with an oral surgeon.
Watch the site until it heals.
Expect follow-up until the gum closes. If healing is slow, antiseptic rinses such as chlorhexidine are used until it does.1
ORN staging
How doctors describe how severe ORN is.
The 2024 guideline recommends the ClinRad system for staging ORN. ClinRad looks at how deep the dead bone goes on imaging and whether bone is exposed or a fistula is present. In plain terms, it separates early or partial-thickness ORN from disease that runs through the full height of the jaw.
In testing, ClinRad did a better job of identifying serious ORN (a jaw fracture or the need to remove part of the jaw) than 15 existing systems. It also accounts for ORN in the upper jaw, which some older systems missed.2
- Partial-thickness ORN. Necrosis limited to the bone around the teeth, or not through the full jaw. ClinRad stages I to II. Often managed first without major surgery.1
- Full-thickness or extensive ORN. ClinRad stage III, and some stage II cases. More likely to need surgery.1
Your stage is assigned by the team treating the ORN.
Osteoradionecrosis treatment
How ORN is treated, and what the evidence says.
Treatment depends on the stage. Early ORN is often managed with cleaning, rinses, antibiotics for infection, and sometimes pentoxifylline with vitamin E. Advanced ORN may need surgery. Advanced ORN is managed by oral and maxillofacial surgeons and the oncology team, with your dentist coordinating.
| Treatment | What it involves | What the evidence shows |
|---|---|---|
| Conservative care | Keeping the area clean, antiseptic rinses, smoothing sharp bone, removing loose fragments | The usual first step for partial-thickness disease, sometimes with minor procedures done through the mouth.1 |
| Antibiotics | Used when the area is infected, and sometimes alongside other medicines | Treat infection. The guideline notes they add benefit when combined with pentoxifylline and vitamin E.1 |
| Pentoxifylline and vitamin E (PENTO) | Daily pills for months, prescribed by your treating team | The guideline says pentoxifylline may be used for ORN of any severity in cancer-free patients, usually with tocopherol, antibiotics, and sometimes a steroid.1 |
| Hyperbaric oxygen (HBO) | Breathing pure oxygen in a pressurized chamber over many sessions | Mixed. A randomized trial found no benefit before extractions (ORN in 6.4% with HBO vs. 5.7% without).4 The guideline calls HBO largely unjustified but allows it with surgery in selected cases.1 |
| Surgery | Removing dead bone through the mouth, or removing part of the jaw and rebuilding it with a free flap | Strong evidence supports surgical management for advanced ORN.1 |
Osteoradionecrosis dental care in Jacksonville
Dr. Henley’s role, and what it isn’t.
Dr. Henley is a general dentist. He helps prevent ORN, cares for teeth before, during, and after radiation, assesses ORN risk before any procedure, and keeps your oncology team informed. He is a member of the Baptist MD Anderson Head and Neck Tumor Board. He doesn’t treat cancer, and his care never replaces oncology follow-up.
What we do
- Dental evaluation before radiation. Referred patients are typically seen within 72 hours. Dr. Henley works to finish needed treatment before your start date. When time is short, he treats by risk and shares the plan with your team. More on dental care for cancer treatment.
- Prevention after radiation. Custom fluoride trays, help with dry mouth and trismus, and regular exams.
- ORN risk assessment before procedures. Before any extraction or surgery, Dr. Henley reviews your radiation history and, when available, the dose to the area. Some extractions are referred to an oral and maxillofacial surgeon.
- Coordination. If he sees signs of possible ORN, he documents what he finds and contacts your oncology team or surgeon. Referring teams get a written summary.
For physicians and nurse navigators
Please include radiation dates, jaw dose if known, and any bone-modifying drugs. Physician line (904) 762-5616, fax (904) 212-4045, or our physician referrals page.
Our office doesn’t bill medical insurance. We’re an out-of-network dental office; many dental plans still pay part of the cost, and you’ll get the fee for each step in writing before treatment starts.
ORN vs. MRONJ
Osteoradionecrosis vs. medication-related osteonecrosis.
Both cause jawbone that dies and won’t heal, and both are often triggered by extractions. The cause is different. ORN follows radiation to the head and neck. MRONJ follows bone-modifying drugs such as zoledronic acid or denosumab. By definition, MRONJ is diagnosed only in people who have not had radiation to the jaws.
| Osteoradionecrosis (ORN) | Medication-related osteonecrosis (MRONJ) | |
|---|---|---|
| Cause | Radiation therapy to the head and neck1 | Antiresorptive drugs (bisphosphonates, denosumab), alone or with antiangiogenic drugs5 |
| Where in the jaw | Only inside the radiation field, mostly the lower jaw | Anywhere in either jaw |
| Definition | Imaging changes and/or exposed or probeable bone in an irradiated site; no minimum time required1 | Exposed or probeable bone for more than 8 weeks, with no history of jaw radiation or obvious cancer in the jaw5 |
| Learn more | This page and our head and neck cancer page | Osteoporosis medications and your dental health |
When to call
When to call us, and when to call your cancer team.
If you’ve had head and neck radiation, call if you notice bone showing in your mouth, a sore that hasn’t healed in two weeks, a tooth that breaks or loosens, or new numbness in your lip or chin. Call your oncology team or go to an emergency room for spreading swelling, fever, or trouble swallowing or breathing.
Call our office (904.398.1549)
- A rough or hard spot in your gums that feels like bone
- A gum sore or extraction site that isn’t closing
- A broken, loose, or painful tooth, especially in the radiation area
Call your oncology team or seek emergency care
- Swelling spreading into your neck or toward your eye
- Fever with jaw pain or drainage
- Trouble swallowing or breathing
- A sudden change in your bite
Any new lump or sore that doesn’t heal also needs to be seen by your cancer team. Keep every follow-up your oncologist schedules.
Frequently asked questions
Questions about osteoradionecrosis of the jaw.
Where can I get dental care for osteoradionecrosis risk in Jacksonville?
Dr. Henley sees head and neck cancer survivors at our San Marco office, 3675 Hendricks Avenue. He provides dental care before and after radiation, ORN risk assessment before procedures, and coordination with your oncology team. Advanced ORN is treated by oral and maxillofacial surgeons and oncology teams. Call 904.398.1549, or have your care team use our physician referrals page.
What is osteoradionecrosis of the jaw?
It’s jawbone that was damaged by radiation for head and neck cancer and breaks down instead of healing. It may show as exposed bone in the mouth, as changes on X-rays or scans, or both. It often starts after an extraction or injury in bone that received a high dose, sometimes years after treatment ends.
Does ORN have to last three months to count?
Not anymore. Many older definitions required exposed bone that hadn’t healed for three months, and you’ll still see that in articles. The 2024 ISOO-MASCC-ASCO guideline dropped the time requirement and includes changes seen only on imaging. That lets teams recognize ORN earlier.
What are the first symptoms of ORN?
Often a small patch of exposed bone in the gums that doesn’t close. It may not hurt at first. Others notice an ache, swelling, a bad taste, or lip numbness. Some early ORN shows only on imaging.
Can I have a tooth pulled after radiation?
Sometimes, but it needs planning. In high-dose bone, a root canal, crown, or filling is preferred whenever it’s reasonable. If the tooth must come out, your dentist should review your radiation dose first, handle the tissue gently, and involve your care team. Some extractions are better done by an oral and maxillofacial surgeon. See tooth extractions.
Should I have teeth removed before radiation?
Only teeth with a poor long-term outlook in the high-dose area, not healthy teeth. Guidelines suggest removing them at least two weeks before radiation, as long as that doesn’t delay cancer treatment. A pre-radiation dental exam sorts out which teeth are worth keeping.
Does hyperbaric oxygen prevent or treat ORN?
The evidence is mixed. A randomized trial of patients needing extractions in irradiated lower jaws found no meaningful difference in ORN with or without hyperbaric oxygen. The 2024 guideline does not recommend it routinely before extractions, though it may be used with surgery in selected cases. Your surgical and oncology team makes that call.
What is PENTO?
PENTO is pentoxifylline combined with tocopherol (vitamin E). The 2024 guideline says they may be used for ORN in cancer-free patients, and considered around invasive dental procedures in high-dose bone, though the evidence is still limited. They’re prescribed by your treating team.
Is ORN the same as the jaw problem from osteoporosis drugs?
No. That’s MRONJ, caused by bone-modifying drugs such as bisphosphonates or denosumab. It looks similar, but ORN comes from radiation and stays within the radiation field. Some patients have both risks. Tell every dentist about radiation and about these medications. Read more on osteoporosis medications and your dental health.
Does seeing Dr. Henley replace my oncology follow-up?
No. Dr. Henley takes care of your teeth, gums, and jaw and keeps your oncology team informed. Your cancer team handles surveillance for the cancer itself and decides on medical or surgical treatment for ORN. Keep every follow-up appointment they schedule.
Your next step
Had radiation? Let’s keep your teeth, and your jaw, out of trouble.
Whether radiation is ahead of you or years behind you, a careful exam and a prevention plan are your strongest protection against ORN. Care teams can reach Dr. Henley through the physician line at (904) 762-5616.
CJ Henley, DMD, PA3675 Hendricks Avenue
Jacksonville, FL 32207
Prefer a nonurgent text? 904.762.5616 is our practice on-call and text line. Please don’t send sensitive health information by text, and call for anything urgent.
Related pages
Sources
- Peterson DE, Koyfman SA, Yarom N, et al. Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline. J Clin Oncol. 2024;42(16):1975-1996.
- Watson EE, Hueniken K, Lee J, et al. Development and Standardization of an Osteoradionecrosis Classification System in Head and Neck Cancer: Implementation of a Risk-Based Model. J Clin Oncol. 2024;42(16):1922-1933.
- Balermpas P, van Timmeren JE, Knierim DJ, Guckenberger M, Ciernik IF. Dental extraction, intensity-modulated radiotherapy of head and neck cancer, and osteoradionecrosis: A systematic review and meta-analysis. Strahlenther Onkol. 2022;198(3):219-228.
- Shaw RJ, Butterworth CJ, Silcocks P, et al. HOPON (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis): A Randomized Controlled Trial of Hyperbaric Oxygen to Prevent Osteoradionecrosis of the Irradiated Mandible After Dentoalveolar Surgery. Int J Radiat Oncol Biol Phys. 2019;104(3):530-539.
- Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons’ Position Paper on Medication-Related Osteonecrosis of the Jaws—2022 Update. J Oral Maxillofac Surg. 2022;80(5):920-943.
- National Institute of Dental and Craniofacial Research. Oral Complications of Cancer Treatment: What the Dental Team Can Do. National Institutes of Health.
- Naseer A, Brennan S, MacCarthy D, O’Connell JE, O’Sullivan E, Leech M. Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy. Head Neck. 2025;47(2):472-484.