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Providing Hyperbaric Oxygen Therapy to Help Accelerate Healing Since 1999

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. Robert E. Marx, DDS developed the following original staging system for classifying and treatment mandibular osteoradionecrosis (ORN) and treating former head and neck cancer patients prior to extraction of teeth.*

Stage I ORN/Extraction

Patients with exposed bone who have no serious manifestations of those in Stage III. Begin with 30 HBO2 treatments with no debridement or only minor bony debridement. If patient progresses, give 10 additional HBO2 treatments.

Stage II ORN

If not progressing, Stage II patients should receive surgical debridement and 30 HBO2 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 HBO2 treatments prior to resection followed by 10 post-resection treatments.

Benefits of HBO2

  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 treatments may vary according to the severity of the condition.

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.