Leucocyte-rich and platelet-rich fibrin for the treatment of bisphosphonate-related osteonecrosis of the jaw: a prospective feasibility study

Use of Leukocyte- and Platelet-Rich Fibrin in the Treatment of Medication-Related Osteonecrosis of the Jaws

Lesions associated with medication-related osteonecrosis of the jaws (MRONJ) are refractory to different treatment approaches. Hence, auxiliary approaches capable of improving patient outcomes should be explored. Leukocyte- and platelet-rich fibrin (LPRF) is a second-generation platelet concentrate (natural autologous fibrin matrix). It shows anti-infectious activity through immune regulation and accelerates the angiogenesis and multiplication of fibroblasts and osteoblasts; in consequence, it stimulates soft tissue healing and prevents exposure of the alveolar bone in the oral cavity. This report describes 2 cases involving women with breast cancer who were being treated with zoledronic acid and exhibited advanced MRONJ. In case 1, MRONJ developed in the maxilla after dental extraction; in case 2, it was assumed that MRONJ arose spontaneously in the mandible because no other risk factors could be detected. These cases were managed with surgical resection of the necrotic bone followed by placement of an LPRF membrane. Complete wound healing and intact mucosal cover were achieved. At clinical and tomographic follow-up after 2 years, there were no oral lesions or complaints. Therefore, this could be a noninvasive, quick, and alternative approach to manage bone exposure. The LPRF membrane contributes to a successful outcome and acts as a physical barrier against micro-organisms, thus preventing secondary infections.

Medication-Related Osteonecrosis of the Jaw: New Insights into Molecular Mechanisms and Cellular Therapeutic Approaches

In recent years, medication-related osteonecrosis of the jaw (MRONJ) became an arising disease due to the important antiresorptive drug prescriptions to treat oncologic and osteoporotic patients, as well as the use of new antiangiogenic drugs such as VEGF antagonist. So far, MRONJ physiopathogenesis still remains unclear. Aiming to better understand MRONJ physiopathology, the first objective of this review would be to highlight major molecular mechanisms that are known to be involved in bone formation and remodeling. Recent development in MRONJ pharmacological treatments showed good results; however, those treatments are not curative and could have major side effects. In parallel to pharmacological treatments, MSC grafts appeared to be beneficial in the treatment of MRONJ, in multiple aspects: (1) recruitment and stimulation of local or regional endogenous cells to differentiate into osteoblasts and thus bone formation, (2) beneficial impact on bone remodeling, and (3) immune-modulatory properties that decrease inflammation. In this context, the second objective of this manuscript would be to summarize the molecular regulatory events controlling osteogenic differentiation, bone remodeling, and osteoimmunology and potential beneficial effects of MSC related to those aspects, in order to apprehend MRONJ and to develop new therapeutic approaches.

Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents

Background

The clinical management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bisphosphonates and other antiresorptive agents is subject to controversy. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed guidelines for the correct management of the disorder which are revised and updated by a panel of experts.

Material and Methods

The present systematic review analyzes the different treatments currently used to treat this clinical condition, based on the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement published in 2009. An electronic Medline search was made of the PubMed database, covering the period 2006-2014. The last search date was 31 December 2014.

Results

A total of 29 articles were selected from the initial search according to the different drugs implicated in the appearance of osteonecrosis; the treatment modality used according to the stage of the disease; and the recorded success rate.

Conclusions

It is currently still recommended that the management of MRONJ should be decided according to the stage of the disease – conservative treatment being preferred in early stages without symptoms, while surgical management is preferred in the case of bone exposure with symptoms.

Key words:Osteonecrosis, medication, bisphosphonates, treatments, review

Surgery Combined with LPRF in Denosumab Osteonecrosis of the Jaw: Case Report

Abstract This paper describes two cases in which the use of leucocyte-rich and platelet-rich fibrin (LPRF) combined with bone resection did not result in complete tissue response in the treatment of medication-related osteonecrosis of the jaw (MRONJ). It has been recently described in patients receiving subcutaneous administration of RANK-inhibitors, such as Denosumab, and anti-angiogenic drugs, such as Bevacizumab, as observed in our cases. Due to promising results in recent studies, more patients will receive these medications in order to avoid skeletal complications due to metastatic bone disease and, therefore, this scenario has a potential to become a comparable challenge to the bisphosphonate- induced jaw necrosis in the area of Oral and Maxillofacial Surgery. No convincing surgical technique has been described to overcome the non-healing mucosal lesions with exposed bone due to RANK-inhibitor therapy. Based on the findings in the literature and in both cases described herein can be concluded that the use of LPRF should be considered in the treatment of patients with DRONJ.

Medication-related osteonecrosis of the jaw: Is autologous platelet concentrate application effective for prevention and treatment? A systematic review

PURPOSE

To date, no ideal strategy has been established for treating or preventing medication-related osteonecrosis of the jaw (MRONJ). The aim of the present work was to perform a systematic literature review to determine the efficacy of autologous platelet concentrate (APC) application, for prevention or treatment of MRONJ, together with surgical debridement.

MATERIAL AND METHODS

An electronic search was performed using MEDLINE (PubMed), EMBASE, and Cochrane databases until January 2015 using the following search terms: osteonecrosis, bisphosphonates, antiresorptive, antiangiogenic therapy, BRONJ, platelet concentrate, PRP, PRF, and PRGF. Two reviewers assessed the eligibility of articles independently and extracted key data. The methodology used met PRISMA criteria. The Newcastle-Ottawa scale was used to assess the quality of the articles.

RESULTS

Preventive applications of platelet-rich plasma (PLP) were reported in 697 dental extractions in patients taking bisphosphonates intravenously, of whom seven patients developed osteonecrosis (five mandibular and two maxillary). In cases of established osteonecrosis, eight studies reported treatment by surgery combined with APC (seven with PRP and one with leukocyte-rich and platelet-rich fibrin) in 123 patients (34 men and 89 women) with ONJ, who received 157 treatments, of which 135 achieved complete resolution (85.98%).

CONCLUSION

There are no published scientific data to sufficiently support any specific treatment protocol, including the use of APC together with surgical debridement, for the management of MRONJ. Randomized controlled clinical trials of the use of APC are needed.

Platelet preparations in dentistry: How? Why? Where? When?

The aim of this article is to review the outcomes of platelet preparations in dentistry. A structured electronic search discovered 348 articles, which described the use of autologous platelet concentrates with a relevance to clinical dentistry. Among these articles, 220 articles investigated platelet rich plasma, 99 investigated platelet rich fibrin, 22 investigated plasma rich in growth factors and 7 investigated the use of concentrated growth factors. Several studies reported beneficial treament outcomes in terms of enhanced bone and soft tissue regeneration.