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Delivering hyperbaric oxygen therapy and rehabilitation services to advance wound healing, optimize patient outcomes and improve quality of life

Marx Protocol for ORN and Tooth Extraction

The most widely accepted and extensively documented indication for hyperbaric oxygen in chronic radiation injury is its application in the treatment and prevention of radiation necrosis of the mandible or jaw bone.  Hyox follows the Marx Protocol for hyperbaric oxygen therapy in such cases as developed by Robert E. Marx, DDS.  The Marx Protocol is the original staging system for classifying and treatment mandibular osteoradionecrosis (ORN) and treating former head and neck cancer patients prior to extraction of teeth* since the viability of soft tissue may have been compromised due to radiation therapy.

A review of the Marx Protocol for the prevention and management of ORN by coming surgery and hyperbaric oxygen therapy concludes “by using the Marx protocols in the treatment of ORN, more than 95 per cent of patients can be successfully cured of their disease with predictable, functional and aesthetically acceptable outcomes.”

Stage I ORN/Extraction

Patients with exposed bone who have no serious manifestations of those in Stage III. Begin with 30 hyperbaric oxygen treatments with no debridement or only minor bony debridement. If patient progresses, HyOx will administer 10 additional hyperbaric oxygen treatments.

Stage II ORN

If not progressing, Stage II patients should receive surgical debridement and 30 hyperbaric oxygen treatments followed by 10 post-operative treatments. Surgery for Stage II patients must maintain mandibular continuity.


If mandibular continuity is not achieved, Stage III patients are entered into a reconstructive protocol where a mandibular resection if followed by a planned reconstruction. All necrotic bone must be surgically eradicated. Stage III patients receive 30 hyperbaric oxygen treatments prior to resection followed by 10 post-resection treatments.

Benefits of the Marx Protocol and Hyperbaric Oxygen Therapy

  1. Vascular improvement
  2. Expedited healing of ORN
  3. Better tolerance to surgical wounding prior to oral surgery
  4. Prevention of mandibular necrosis as a result of tooth extraction
  5. Freedom from pain
  6. Restoration of mandibular function and wearing of dental appliances, if needed
  7. Maintenance of intact mucosa and skin over all bone

*The number of hyperbaric oxygen treatments may vary according to the severity of the condition and healing progression.  Refer to HyOx prior to any invasive surgery of the head and neck, including tooth extraction,* in previously irradiated patients to prevent ORN from occurring.

*There is a study of irradiated patients undergoing dental extractions that showed a 98.5 percent success rate.

Other References: (1) Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: A randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Am Dent Assoc 1985;11:49-54. (2) Undersea and Hyperbaric Medical Society. The Hyperbaric Oxgyen Therapy Committee Report, 2005. (3) Marx RE. Osteoradionecrosis of the Jaws: Review and Update. Assistant Chairman of Oral and Maxillofacial Surgery, Wilford Hall USAF Medical Center, San Antonio, TX. HBO Review, Vol. 5, No. 2.