Osteoradionecrosis of the Jaw: HBOT and the Marx Protocol
Osteoradionecrosis of the jaw (ORN) is a serious complication of head and neck radiation. The Marx Protocol uses HBOT before and after surgery to improve healing.
Osteoradionecrosis of the Jaw: HBOT and the Marx Protocol
Osteoradionecrosis of the jaw is one of the most serious long-term complications of head and neck radiation therapy. It’s also one of the clearest applications of HBOT — supported by decades of clinical experience and an established treatment protocol that bears the name of the physician who developed it.
What Osteoradionecrosis Is
Radiation therapy for cancers of the throat, mouth, tongue, salivary glands, and other head and neck structures deposits significant energy in the surrounding tissue. Over time, this damages blood vessels and reduces blood supply to the jawbone. The result is hypovascular (low blood flow), hypoxic (low oxygen), and hypocellular (few living cells) bone — what the field calls the “three H’s.”
Bone in this state can’t heal. A wound that a healthy person’s jaw would recover from in days or weeks won’t close in irradiated tissue. Exposed bone can die, become infected, and in serious cases require surgical removal.
The patients most at risk are those who received high-dose radiation to the head and neck. Dental extractions in the irradiated field are a major trigger. Pulling a tooth from irradiated bone creates a socket that simply can’t heal normally.
The Marx Protocol
Robert Marx, a maxillofacial surgeon, developed the foundational protocol for managing ORN in 1985. His paper established both the mechanism of radiation injury and the HBOT protocol to address it.
Marx et al. (1985) — PMID: 4017834
The Marx Protocol calls for:
- 20 HBOT sessions before dental surgery or ORN surgery
- 10 HBOT sessions after surgery
- Sessions at 2.4 ATA breathing 100% oxygen, 90 minutes each
The pre-operative sessions work to improve oxygen tension in the hypoxic tissue before the surgical wound is created. Post-operative sessions support healing in a wound bed that still has impaired vascularity.
Prevention: HBOT Before Dental Work in an Irradiated Field
The most important point for head and neck cancer survivors: tell your dentist that you’ve received radiation to the jaw or surrounding area before any dental work happens.
If you need a tooth extracted from tissue that was in a radiation field, you may need prophylactic HBOT before and after the extraction. This is true even years after radiation ended — radiation injury to bone is permanent. The tissue doesn’t recover its vascularity over time.
The protocol for prophylactic use (preventing ORN before dental surgery) follows the same Marx Protocol structure: 20 sessions pre-op, 10 sessions post-op.
Don’t schedule dental extractions in a previously irradiated field without consulting both your radiation oncologist and, ideally, a hyperbaric physician or oral and maxillofacial surgeon familiar with ORN management.
Treating Established ORN
When ORN has already developed, treatment depends on staging.
Early-stage ORN (Stage I-II in most classification systems) may be managed with HBOT alone or with minor debridement and HBOT. Exposed bone is present but hasn’t progressed to frank necrosis or pathological fracture.
Late-stage ORN (Stage III) typically involves extensive bone death and may require surgical resection followed by reconstruction, with HBOT as an integral part of the perioperative plan.
HBOT works by increasing oxygen delivery to the radiation-damaged tissue, stimulating angiogenesis (new blood vessel growth), and supporting the collagen synthesis needed for wound healing. It doesn’t reverse the underlying radiation damage. What it does is create a better environment for healing to occur — or for surgery to succeed.
Who Treats ORN
Management of established ORN typically involves an oral and maxillofacial surgeon, a hyperbaric physician, and your oncologist working together. Single-specialist management is usually insufficient for anything beyond very early-stage ORN.
Insurance Coverage
ORN and radiation-induced soft tissue injury are FDA-approved indications for HBOT. Medicare and most commercial insurers may cover HBOT when ORN criteria are documented and the clinical record supports it. Verify specific coverage with your facility’s billing team.
FAQ
Q: What is osteoradionecrosis of the jaw? Bone death from radiation damage to blood vessels. The jaw can no longer heal from injury or surgery. A complication of head and neck radiation therapy.
Q: What is the Marx Protocol? 20 HBOT sessions before surgery, 10 sessions after, at 2.4 ATA, 90 minutes each. Developed by Robert Marx in 1985 (PMID: 4017834).
Q: Do I need HBOT before tooth extraction after radiation? Possibly. Tell your dentist about your radiation history first. A hyperbaric physician can evaluate whether prophylactic HBOT is warranted.
Q: Is ORN treatment covered by insurance? It’s FDA-approved. Medicare and many commercial plans may cover it when clinical criteria are documented.
Related: Radiation Injury and HBOT | Insurance Coverage for HBOT | HBOT Combination Therapy
Medical Disclaimer: This content is for informational purposes only and does not constitute medical advice. Osteoradionecrosis requires evaluation and management by qualified physicians including oral surgeons, hyperbaric physicians, and oncologists. Always consult your care team about your specific situation. This site does not establish a doctor-patient relationship.