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Vescovi P, Giovannacci I, Otto S, Manfredi M, Merigo E, Fornaini C, Nammour S, Meleti M. Medication-Related Osteonecrosis of the Jaw: An Autofluorescence-Guided Surgical Approach Performed with Er:YAG Laser. Photomed Laser Surg 2016. [PMID: 26226174 DOI: 10.1089/pho.2015.3927] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The aim of this study was to propose an autofluorescence (AF)-guided surgical approach performed with Er:YAG laser and Nd:YAG low-level laser therapy (LLLT). BACKGROUND DATA Medication-related osteonecrosis of the jaw (MRONJ) therapy remains an unresolved problem. The proposed conservative and surgical treatment regimens are associated with contradictory success rates. However, the increased experience with MRONJ management suggests that surgical therapy can halt disease progression, and can allow a histology-based diagnosis of osteonecrosis. Surgical approach with Er:YAG laser is associated with significantly better results compared with medical treatment and traditional surgical approaches. One of the difficulties encountered during surgical removal of a MRONJ is the precise individuation of necrotic bone margins. PATIENT AND METHODS A case of Stage III maxillary osteonecrosis treated with a new surgical approach is presented. RESULTS After 7 months of follow-up, complete mucosal healing was evident, and the patient was free of symptoms. Such a technique allowed a highly accurate and minimally invasive approach through the selective ablation of the non-/hypofluorescent areas. CONCLUSIONS Taking into account the advantages of laser therapy and the possible effectiveness of AF in highlighting surgical margins, this approach would probably achieve excellent outcomes.
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Affiliation(s)
- Paolo Vescovi
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
| | - Ilaria Giovannacci
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
| | - Sven Otto
- 2 Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians Universität München , Munich, Germany
| | - Maddalena Manfredi
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
| | - Elisabetta Merigo
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
| | - Carlo Fornaini
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
| | - Samir Nammour
- 3 Department of Dental Sciences, Faculty of Medicine, University of Liege , Liege, Belgium
| | - Marco Meleti
- 1 Department of Biomedical, Biotechnological and Translational Sciences - Center of Oral Laser Surgery and Oral Pathology, Dental School, University of Parma , Parma, Italy
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Identifying MRONJ-affected bone with digital fusion of functional imaging (FI) and cone-beam computed tomography (CBCT): case reports and hypothesis. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 123:e106-e116. [PMID: 28108142 DOI: 10.1016/j.oooo.2016.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 01/26/2023]
Abstract
Surgical debridement of medication-related osteonecrosis of the jaw (MRONJ) lesions is far less predictable than lesion resection. Margins for surgical debridement are guided by surrogate markers of bone viability, such as bleeding and bone fluorescence, which limit debridement to visibly necrotic bone. In contrast, surgical resection is extensive, including a substantial portion of surrounding bone. The concept that the MRONJ lesion is a composite of affected but viable ("compromised") and necrotic bone is supported by histopathological data. Hence, removing only the necrotic bone during lesion debridement could inadvertently leave behind residual compromised bone in the lesion, subsequently contributing to persistence or reestablishment of the lesion. Using 2 case reports, this manuscript illustrates a novel assessment of the MRONJ lesion to enable demarcation of both the compromised and necrotic portions of the lesion. This assessment uses tumor-surveillance functional bone imaging data that may already be available for cancer patients with MRONJ and fuses these data digitally with computed tomography/cone-beam computed tomography imaging of the jaw obtained during MRONJ assessment. If validated, preoperative functional imaging-based assessment of the MRONJ lesion could enable surgeons to eliminate both the compromised and nonviable portions of the lesion precisely with conservative debridement, matching surgical resection in outcome.
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Comparison of auto-fluorescence and tetracycline fluorescence for guided bone surgery of medication-related osteonecrosis of the jaw: a randomized controlled feasibility study. Int J Oral Maxillofac Surg 2016; 46:157-166. [PMID: 27856150 DOI: 10.1016/j.ijom.2016.10.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/16/2016] [Accepted: 10/20/2016] [Indexed: 11/20/2022]
Abstract
Recent studies have indicated that bone shows auto-fluorescence under an appropriate fluorescence lamp. The aim of this preliminary study was to compare the success rates of the established tetracycline fluorescence-guided bone surgery with auto-fluorescence-guided bone surgery in the treatment of medication-related osteonecrosis of the jaw (MRONJ). Forty patients suffering from MRONJ were referred for surgical treatment and were divided randomly into two groups: auto-fluorescence (n=20) or tetracycline fluorescence (n=20) guided bone surgery. The primary endpoint was treatment success, defined as the absence of exposed bone at 8 weeks after surgery. Secondary outcomes assessed were mucosal integrity, signs of infection, pain, and loss of sensitivity; these were evaluated descriptively at 10 days, 8 weeks, 6 months, and 1 year after surgery. At 8 weeks postoperative, 18/20 patients (90%) in the auto-fluorescence group and 17/20 patients (85%) in the tetracycline fluorescence group showed mucosal integrity (P>0.05). At the last follow-up, 94% in the auto-fluorescence group and 89% in the tetracycline fluorescence group presented complete mucosal coverage with no exposed bone, infection, or pain (P>0.05). There was no significant difference between the two techniques for any of the secondary outcomes (P>0.05). The results of this preliminary study show that auto-fluorescence-guided bone surgery has comparable success rates to the established tetracycline fluorescence-guided bone surgery.
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54
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Ruhin B. [Not Available]. REVUE DE STOMATOLOGIE, DE CHIRURGIE MAXILLO-FACIALE ET DE CHIRURGIE ORALE 2016; 117:363-365. [PMID: 27364432 DOI: 10.1016/j.revsto.2016.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/03/2016] [Indexed: 06/06/2023]
Affiliation(s)
- B Ruhin
- Pathologies osseuses des mâchoires, service de chirurgie maxillo-faciale et de stomatologue, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris, France.
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Conservative surgical management of patients with bisphosphonate-related osteonecrosis of the jaws: a series of 120 patients. Br J Oral Maxillofac Surg 2016; 54:930-935. [DOI: 10.1016/j.bjoms.2016.06.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/17/2016] [Indexed: 11/23/2022]
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Multipotent mesenchymal stromal cell sheet therapy for bisphosphonate-related osteonecrosis of the jaw in a rat model. Acta Biomater 2016; 42:400-410. [PMID: 27326918 DOI: 10.1016/j.actbio.2016.06.022] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 06/03/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
UNLABELLED Bisphosphonates (BPs) inhibit bone resorption and are frequently used to treat osteoporosis, bone metastasis, and other conditions that result in bone fragility. However, numerous studies have reported that BPs are closely related to the development of osteonecrosis of the jaw (BRONJ), which is an intractable disease. Recent studies have demonstrated that intravenous infusion of multipotent mesenchymal stromal cells (MSCs) is effective for the treatment of BRONJ-like disease models. However, the stability of injected MSCs is relatively low. In this study, the protein level of vascular endothelial growth factor in BP-treated MSCs was significantly lower than untreated-MSCs. The mRNA expression levels of receptor activator of nuclear factor κ-B ligand and osteoprotegerin were significantly decreased in BP-treated MSCs. We developed a tissue-engineered cell sheet of allogeneic enhanced green fluorescent protein (EGFP)-labeled MSCs and investigated the effect of MSC sheet transplantation in a BRONJ-like rat model. The MSC sheet group showed wound healing in most cases compared with the control group and MSC intravenous injection group (occurrence of bone exposure: 12.5% compared with 80% and 100%, respectively). Immunofluorescence staining revealed that EGFP-positive cells were localized around newly formed blood vessels in the transplanted sub-mucosa at 2weeks after transplantation. Blood vessels were significantly observed in the MSC sheet group compared to in the control group and MSC intravenous injection group (106±9.6 compared with 40±5.3 and 62±10.2 vessels/mm(2), respectively). These results suggest that allogeneic MSC sheet transplantation is a promising alternative approach for treating BRONJ. STATEMENT OF SIGNIFICANCE Bisphosphonates are frequently used to treat osteoporosis, bone metastasis of various cancers, and other diseases. However, bisphosphonate related-osteonecrosis of the jaw (BRONJ) is an intractable disease because it often recurs after surgery or is exacerbated following conservative treatment. Therefore, an alternative approach for treating BRONJ is needed. In this study, we developed a bone marrow-derived multipotent mesenchymal stromal cell (MSC) sheet to treat BRONJ and investigated the effect of MSC sheet transplantation in a rat model of BRONJ-like disease. The MSC sheet transplantation group showed wound healing in most cases, while only minimal healing was observed in the control group and MSC intravenous injection group. Our results suggest that the MSC sheet is a promising alternative approach for the treatment of BRONJ.
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Rodriguez-Lozano FJ, Oñate-Sánchez RE. Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents. Med Oral Patol Oral Cir Bucal 2016; 21:e595-600. [PMID: 27475683 PMCID: PMC5005097 DOI: 10.4317/medoral.20980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
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
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Affiliation(s)
- F-J Rodriguez-Lozano
- Clínica Odontológica Universitaria, Unidad Pacientes Especiales y Gerodontología, University of Murcia, IMIB-Arrixaca. Morales Meseguer Hospital, Avda. Marqués de los Vélez s/n, 30007- Murcia, Spain,
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Klingelhöffer C, Zeman F, Meier J, Reichert TE, Ettl T. Evaluation of surgical outcome and influencing risk factors in patients with medication-related osteonecrosis of the jaws. J Craniomaxillofac Surg 2016; 44:1694-1699. [PMID: 27591091 DOI: 10.1016/j.jcms.2016.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/29/2016] [Accepted: 08/01/2016] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Surgical treatment of the medication-related osteonecrosis of the jaw (MRONJ) is still challenging. We examined the outcome of the resection of osteonecrotic lesions and the influence of potential risk factors on the operative success. METHODS Seventy six surgical interventions on 40 patients were evaluated in a prospective design with a mean follow-up of 55 weeks. Primary endpoints were: (i) maintenance of the mucosal closure and (ii) decrease of MRONJ stage. Influential variables included preoperative duration, location and diameter of MRONJ, duration and change of antiresorptive therapy, presence of actinomyces species. RESULTS Only in 27.6% of cases long-term maintenance of the mucosal closure was achieved. However, stage II patients decreased to stage I in 81% after surgery (p < 0.01) and stage III patients improved in 83% of cases (OR = 8.08; p = 0.07). Stage I patients profited only in 38% by surgical intervention. MRONJ recurrence after surgery was associated with extended preoperative MRONJ duration (p = 0.015). There was no significance of further influential variables, but MRONJ of the upper jaw seems prognostically more favorable. CONCLUSION Advanced stages of MRONJ benefit from surgical treatment, whereas stage I diseases may also be treated conservatively. An early intervention reduces the risk of recurrence.
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Affiliation(s)
- Christoph Klingelhöffer
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Florian Zeman
- Department of Clinical Studies, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Johannes Meier
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Torsten Eugen Reichert
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Tobias Ettl
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
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Abstract
Bisphosphonates are widely used for treatment or prevention of bone diseases characterized by high osteoclastic activity. Among the oral medicines used to treat osteoporosis, alendronate has been often used. Despite of the low rate of complications on its use, cases of osteonecrosis of the jaw have been reported on literature after tooth extractions. The main symptoms include pain, tooth mobility, swelling, erythema, and ulceration. The risk factors related to osteonecrosis of the jaw associated with bisphosphonate are exposition time to the medicine, routes of administration, and oral surgical procedures performed. The aim of this work is to report a case of a patient showing osteonecrosis of the jaw associated with the use of oral bisphosphonates after tooth extractions. The patient was treated through the suspension of the alendronate with the removal of the necrotic tissue and the foci of infection. After a year's follow-up, the patient showed no recurrence signs. From the foregoing, the interruption of the alendronate use and the surgical treatment associated to antibiotic therapy showed effective on the patient's treatment.
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Fluorescence-guided surgery for the treatment of medication-related osteonecrosis of the jaw: A prospective cohort study. J Craniomaxillofac Surg 2016; 44:1073-80. [PMID: 27263757 DOI: 10.1016/j.jcms.2016.05.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 04/12/2016] [Accepted: 05/17/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The delineation of the necrotic bone is a crucial step in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ). Several different approaches have been described including the innovative technique of fluorescence-guided surgery. However, until now there is a lack of data regarding the outcome. Therefore, the aim of the present study is to investigate the long-term success rates of fluorescence-guided surgery in the treatment of MRONJ. PATIENTS AND METHODS 54 Patients were prospectively assigned for surgical treatment of medication-related osteonecrosis of the jaw using fluorescence-guided surgery. Patients received doxycycline 100 mg twice a day for at least seven days preoperatively. Surgical treatment of MRONJ included complete removal of necrotic bone, which was monitored using the visual enhanced lesion scope (Velscope), followed by smoothening sharp bony edges and meticulous wound closure. Procedure success was assessed as postoperative maintenance of full mucosal coverage without pain, infection or bone exposure during regular follow-up. RESULTS The study included a total of 54 patients (32 female and 22 male, mean age 71.4 ± 9.2 years). In the last follow-up an intact mucosa and absence of exposed bone, pain or signs of infection was identified in 47 of 54 patients (87%) and 56 of 65 lesions (86.2%) after first surgery using fluorescence-guidance. In 4 patients with 6 lesions a second fluorescence-guided surgery was necessary to achieve complete mucosal closure. Respectively, including the case with second surgical attempt 51 of 54 patients (94.4%) and 62 of 65 lesions (95.4%) showed complete mucosal healing. CONCLUSION The study shows that fluorescence-guided surgery is a safe and successful treatment option which can be considered for all stages of MRONJ. The technique seems also promising for MRONJ cases under denosumab.
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Does Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography Facilitate Treatment of Medication-Related Osteonecrosis of the Jaw? J Oral Maxillofac Surg 2016; 74:945-58. [DOI: 10.1016/j.joms.2015.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 12/31/2022]
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Ruggiero SL, Kohn N. Disease Stage and Mode of Therapy Are Important Determinants of Treatment Outcomes for Medication-Related Osteonecrosis of the Jaw. J Oral Maxillofac Surg 2016; 73:S94-S100. [PMID: 26608159 DOI: 10.1016/j.joms.2015.09.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The treatment of patients with medication-related osteonecrosis of the jaw (MRONJ) is challenging. The purpose of the present study was to estimate the frequency and identify the factors associated with clinical improvement during treatment. PATIENTS AND METHODS We designed and implemented a retrospective cohort study and enrolled a sample of subjects diagnosed with MRONJ between 2004 and 2015. The primary predictor variables were a set of heterogeneous variables grouped into the following categories: demographic (age and gender) and clinical (location of necrosis, therapy duration, medication type, disease stage, and treatment type). The primary outcome variable was the treatment outcome, defined as stable or worse and improved or healed. The descriptive, bivariate, and multiple logistic statistics were computed, and statistical significance was defined as P < .05. RESULTS The sample included 337 subjects with a mean age of 68.9 years. Of the 337 subjects, 256 were women (76%). A total of 143 patients (42.2%) experienced spontaneous necrosis. Twenty-four (7.1%) had had exposure to targeted antiangiogenic agents. Those with stage 1 or 2 disease were more likely to have better outcomes than those with stage 3 disease (stage 1, adjusted odds ratio [OR] 3.4, P = .005; stage 2, adjusted OR 2.2, P = .03). Treatment type was a significant variable. Subjects undergoing surgery were 28 times more likely to have a positive outcome than those receiving nonoperative therapy (adjusted OR 28.7, P < .0001). CONCLUSIONS Subjects with MRONJ who presented with less severe disease or who underwent operative treatment were most likely to have improvement or complete healing of their MRONJ-related lesions.
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Affiliation(s)
- Salvatore L Ruggiero
- Clinical Professor, Division of Oral and Maxillofacial Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY; Stony Brook School of Dental Medicine, Stony Brook, NY; New York Center for Orthognathic and Maxillofacial Surgery, New York, NY.
| | - Nina Kohn
- Senior Biostatistician, Biostatistics Unit, Feinstein Institute for Medical Research, North Shore Long Island Jewish Health System, Manhasset, NY
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Rollason V, Laverrière A, MacDonald LCI, Walsh T, Tramèr MR, Vogt‐Ferrier NB. Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev 2016; 2:CD008455. [PMID: 26919630 PMCID: PMC7173706 DOI: 10.1002/14651858.cd008455.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bisphosphonate drugs can be used to prevent and treat osteoporosis and to reduce symptoms and complications of metastatic bone disease; however, they are associated with a rare but serious adverse event: osteonecrosis of the maxillary and mandibular bones. This condition is called bisphosphonate-related osteonecrosis of the jaw or BRONJ. BRONJ is diagnosed when people who are taking, or have previously taken, bisphosphonates have exposed bone in the jaw area for more than eight weeks in the absence of radiation treatment. There is currently no "gold standard" of treatment for BRONJ. The three broad categories of intervention are conservative approaches (e.g. mouth rinse, antibiotics), surgical interventions and adjuvant non-surgical strategies (e.g. hyperbaric oxygen therapy, platelet-rich plasma), which can be used in combination. OBJECTIVES To determine the efficacy and safety of any intervention aimed at treating BRONJ. SEARCH METHODS We searched the following databases to 15 December 2015: the Cochrane Oral Health Group Trials Register, the Cochrane Breast Cancer Group Trials Register (20 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, EMBASE via Ovid, CancerLit via PubMed, CINAHL via EBSCO and AMED via Ovid. We scanned the references cited in retrieved articles and contacted experts in the field, the first authors of included papers, study sponsors, other bisphosphonates investigators and pharmaceutical companies. We searched for ongoing trials through contact with trialists and by searching the US National Institutes of Health Trials Register (clinicaltrials.gov) and the World Health Organization Clinical Trials Registry Platform. We also conducted a grey literature search to September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the effects of any treatment for BRONJ with another treatment or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, assessed the risk of bias in the included trials and extracted data. When in dispute, we consulted a third review author. MAIN RESULTS One small trial at high risk of bias met the inclusion criteria. The trial randomised 49 participants, most of whom had cancer. It compared standard care (defined as surgery, antibiotics and oral rinses at the discretion of the oral-maxillofacial surgeon) to standard care plus hyperbaric oxygen therapy (2 atmospheres twice a day for 40 treatments). The trial measured the percentage of participants who improved or healed at three, six, 12 and 18 months and last contact. It also measured mean weekly pain scores.At three months, the study found that the participants in intervention group were more likely to have an improvement in their osteonecrosis than the standard care group participants (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.01 to 3.74). There was no clear difference between the groups for the outcome 'healed' at three months (RR 3.60, 95% CI 0.87 to 14.82). There was no clear difference between the groups for improvement or healing when they were evaluated at six, 12 and 18 months and last contact.The study did not give any information on adverse events.Although the findings suggest adjunctive hyperbaric oxygen improved BRONJ, the quality of the evidence is very low since the only study was underpowered and was at high risk of bias due to lack of blinding, cross-over of participants between groups and very high attrition (50% at 12 months and 80% at 18 months in this study, which was designed for an intended follow-up of 24 months). AUTHORS' CONCLUSIONS There is a lack of evidence from randomised controlled trials to guide treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). One small trial at high risk of bias evaluated hyperbaric oxygen therapy (HBO) as an adjunct to "standard" care and could not confirm or refute the effectiveness of HBO. There are two ongoing trials of teriparatide treatment for BRONJ. We found no randomised controlled trials of any other BRONJ treatments. High quality randomised controlled trials are needed. We provide recommendations for their focus and design.
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Affiliation(s)
- Victoria Rollason
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
| | - Alexandra Laverrière
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
| | - Laura CI MacDonald
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupJ R Moore Building, Oxford RoadManchesterUK
| | - Tanya Walsh
- School of Dentistry, The University of ManchesterJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Martin R Tramèr
- Geneva University HospitalsDivision of Anaesthesiology, Department APSI4 Gabrielle‐Perret‐GentilGenevaSwitzerland1211
| | - Nicole B Vogt‐Ferrier
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
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Kim HJ, Park TJ, Ahn KM. Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases. Maxillofac Plast Reconstr Surg 2016; 38:6. [PMID: 26870717 PMCID: PMC4735266 DOI: 10.1186/s40902-016-0052-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/21/2016] [Indexed: 11/11/2022] Open
Abstract
Background Intravenous bisphosphonates have been used in metastatic breast cancer patients to reduce pathologic bone fracture and bone pain. However, necrosis of the jaw has been reported in those who received intravenous bisphosphonates. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is caused by dental extraction, dental implant surgery, and denture wearing; however, it occurs spontaneously. The purpose of this study was to report BRONJ in metastatic breast cancer patients. Methods Consecutive 25 female patients were referred from the Department of Oncology from 2008 to 2014 for jaw bone discomfort. Staging of breast cancer, history of bisphosphonate infusion, etiology of BRONJ, and treatment results were reviewed. Average age of the patients was 55.4 years old (38–74). Twelve maxillae and 16 mandibles were involved. Conservative treatments such as irrigation, antibiotic medication, analgesics, and oral gargle were applied for all patients for the initial treatment. Patients who had sequestrum underwent debridement and primary closure. Results The etiologies of BRONJ were dental extraction (19 cases), dental implant (2 cases), and endodontic treatment (1 case). However, three patients did not have any risk factors to cause BRONJ. Three patients died of progression of metastasis during follow-up periods. Surgical debridement was performed in 21 patients with success in 18 patients. Three patients showed recurred bone exposure and infection after operation. Conclusions Prevention of the BRONJ is critical in metastatic breast cancer patients. Conservative treatment to reduce pain, discomfort, and infection is recommended for the initial therapy. However, if there is a sequestrum, surgical debridement and primary closure is the key to treat the BRONJ.
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Affiliation(s)
- Hong-Joon Kim
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Seoul Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 South Korea
| | - Tae-Jun Park
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Seoul Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 South Korea
| | - Kang-Min Ahn
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Seoul Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 South Korea
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Silva LF, Curra C, Munerato MS, Deantoni CC, Matsumoto MA, Cardoso CL, Curi MM. Surgical management of bisphosphonate-related osteonecrosis of the jaws: literature review. Oral Maxillofac Surg 2015; 20:9-17. [PMID: 26659615 DOI: 10.1007/s10006-015-0538-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 12/01/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been performed in an attempt to increase healing rates of the affected cases. This literature review aimed to identify clinical studies of surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in order to assess their surgical treatment modalities, outcome and the follow-up. METHODS A search in the PubMed (Medline) database using specific terms and/or phrases as "bisphosphonate-related osteonecrosis" or "jaw osteonecrosis", and "surgical treatment" or "surgical management" was conducted in order to identify clinical trials and cases of surgical treatment of BRONJ. The review search covered the time period from 2004 to 2014. All studies identified in the search were selected according to the inclusion criteria. Relevant information was recorded according to the following items: author, year, number of patients, BRONJ clinical stage, surgical treatment modality, clinical success, and follow-up. RESULTS The initial database search yielded 345 titles. After filtering, 67 abstracts were selected culminating in 67 full text articles. A variety of surgical approach was found in this review: debridement, sequestrectomy bone resection, and bone reconstruction. Adjunctive therapies included hyperbaric oxygen, laser therapy, growth factors, and ozone. CONCLUSION Although there are many indexed studies about BRONJ, well-documented reports concerning surgical therapeutically techniques are scarce, resulting from a lack of well-established protocols. Considerable differences were found regarding sample size, surgical treatment modalities and outcomes. Clinical studies with larger number of patients and longer follow-up are required to provide best information for each surgical treatment modality and its outcomes.
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Affiliation(s)
| | - Cláudia Curra
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil
| | - Marcelo Salles Munerato
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil.
| | - Carlos Cesar Deantoni
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil
| | | | - Camila Lopes Cardoso
- Universidade do Sagrado Coração, Bauru, SP, Brazil.,Department of Stomatology, Hospital Santa Catarina, Sao Paulo, Brazil
| | - Marcos Martins Curi
- Universidade do Sagrado Coração, Bauru, SP, Brazil.,Department of Stomatology, Hospital Santa Catarina, Sao Paulo, Brazil
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66
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Kim KM, Rhee Y, Kwon YD, Kwon TG, Lee JK, Kim DY. Medication Related Osteonecrosis of the Jaw: 2015 Position Statement of the Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons. J Bone Metab 2015; 22:151-65. [PMID: 26713306 PMCID: PMC4691589 DOI: 10.11005/jbm.2015.22.4.151] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/29/2015] [Accepted: 11/30/2015] [Indexed: 12/28/2022] Open
Abstract
Bisphosphonates are the most widely prescribed drugs for the treatment of osteoporosis, and are also used in malignant bone metastases, multiple myeloma, and Paget's disease, and provide therapeutic efficacy on those diseases. However, it was reported that occurrence of osteonecrosis of the jaw (ONJ) could be related with bisphosphonate exposures, and there have been many cases regarding this issue. Therefore, a clearer definition and treatment guidelines were needed for this disease. The American Society for Bone and Mineral Research (ASBMR) and American Association of Oral and Maxillofacial Surgeons (AAOMS) reported statements on bisphosphonate-related ONJ (BRONJ), and a revised version was recently presented. In the revised edition, the diagnosis BRONJ was changed to medication-related ONJ (MRONJ), which reflects a consideration of the fact that ONJ also occurs for denosumab, a bone resorption inhibitor of the receptor activator of nuclear factor-kappa B ligand (RANKL) antibody family, and bevacizumab, an anti-angiogenesis inhibitor. In 2009, a statement on ONJ was also reported locally by a relevant organization, which has served as basis for clinical treatment in Korea. In addition to the new official stance of the AAOMS and ASBMR, with an increasing pool of ONJ clinical experience, a revised version of the 2009 local statement is needed. As such, the Korean Society for Bone and Mineral Research (KSBMR) and the Korean Association of Oral and Maxillofacial Surgeons (KAOMS) have collectively formed a committee for the preparation of an official statement on MRONJ, and have reviewed recent local and international data to propose guidelines customized for the local Korean situation.
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Affiliation(s)
- Kyoung Min Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Dae Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Tae-Geon Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Korea
| | - Jeong Keun Lee
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
| | - Deog-Yoon Kim
- Department of Nuclear Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
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67
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68
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Yoshiga D, Sasaguri M, Matsuo K, Kokuryou S, Habu M, Oda M, Kodama M, Tsurushima H, Sakaguchi O, Sakurai T, Tanaka J, Morimoto Y, Yoshioka I, Tominaga K. Intraoperative detection of viable bone with fluorescence imaging using Visually Enhanced Lesion Scope in patients with bisphosphonate-related osteonecrosis of the jaw: clinical and pathological evaluation. Osteoporos Int 2015; 26:1997-2006. [PMID: 26037792 DOI: 10.1007/s00198-015-3096-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/27/2015] [Indexed: 01/05/2023]
Abstract
UNLABELLED There is no standard surgical protocol of bisphosphonate-related osteonecrosis of the jaws (BRONJ), because of the impossibility to visualize this feature intraoperatively. The aim of this study was to introduce how to provide preoperative labeling of the viable bone with minocycline bone fluorescence technique (MBFT) by using VELscope® and investigate histopathologically. INTRODUCTION The American Association of Oral and Maxillofacial Surgeons (AAOMS) and the Japanese Society of Oral and Maxillofacial Surgeons (JSOMS) now recommend a more conservative treatment strategy. There is no standard surgical protocol of bisphosphonate-related osteonecrosis of the jaws (BRONJ) because of the impossibility to visualize this feature intraoperatively. The aim of this study was to introduce a mechanism providing preoperative labeling of a viable bone using minocycline bone fluorescence technique (MBFT) with VELscope® and to histopathologically investigate. METHODS This report describes a surgical technique used in six patients with BRONJ who underwent jawbone resection under minocycline bone fluorescence imaging using VELscope®. Subsequently, we investigated and compared the clinical findings using VELscope® and histopathological findings. RESULTS Histopathological examinations showed that the non-fluorescent moiety was consistent with the BRONJ lesions. CONCLUSIONS The surgical treatments that were exactly performed using MBFT with VELscope® offered successful management of BRONJ. This bone fluorescence helped to define the margins of resection, thus improving surgical therapy for extended osteonecrosis.
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Affiliation(s)
- D Yoshiga
- Department of Science of Physical Function, Division of Maxillofacial Surgery, Kyushu Dental University, Fukuoka, Japan,
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69
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Otto S, Marx RE, Tröltzsch M, Ristow O, Ziebart T, Al-Nawas B, Groetz KA, Ehrenfeld M, Mercadante V, Porter S, Bedogni A, Campisi G, Fusco V, Dayisoylu E, Fliefel R, Herlofson BB, Pautke C, Kwon TG, Fedele S. Comments on "diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus". J Bone Miner Res 2015; 30:1113-5. [PMID: 25988662 DOI: 10.1002/jbmr.2525] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/02/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Robert E Marx
- Division of Oral and Maxillofacial Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Matthias Tröltzsch
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Ziebart
- Department of Oral and Maxillofacial Surgery, University of Mainz, Mainz, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University of Mainz, Mainz, Germany
| | - Knut A Groetz
- Department of Oral and Maxillofacial Surgery, Horst-Schmidt-Klinikum, Wiesbaden, Germany
| | - Michael Ehrenfeld
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Valeria Mercadante
- University College London, UCL Eastman Dental Institute, London, United Kingdom
| | - Stephen Porter
- University College London, UCL Eastman Dental Institute, London, United Kingdom
| | - Alberto Bedogni
- University and Hospital Trust of Verona, Department of Surgery, Section of Oral and Maxillofacial Surgery, Verona, Italy
| | - Giuseppina Campisi
- University of Palermo, Department of Surgical, Oncological, and Oral Sciences, Sector of Oral Medicine, Palermo, Italy
| | - Vittorio Fusco
- Hospital "SS. Antonio, Biagio and C. Arrigo", Department of Oncology and Hematology, Unit of Medical Oncology, Alessandria, Italy
| | - Ezher Dayisoylu
- Department of Oral and Maxillofacial Surgery, Baskent University, Faculty of Dentistry, Ankara, Turkey
| | - Riham Fliefel
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany.,Department of Oral and Maxillofacial Surgery, University of Alexandria, Alexandria, Egypt
| | - Bente Brokstad Herlofson
- Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Tae-Geon Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Korea
| | - Stefano Fedele
- University College London, UCL Eastman Dental Institute, and NIHR University College London Hospitals, Biomedical Research Centre, London, United Kingdom
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70
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Treatment strategies and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) with characterization of patients: a systematic review. Int J Oral Maxillofac Surg 2015; 44:568-85. [DOI: 10.1016/j.ijom.2015.01.026] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/28/2015] [Accepted: 01/30/2015] [Indexed: 11/22/2022]
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71
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Nomura T, Shibahara T, Uchiyama T, Yamamoto N, Shibui T, Yakushiji T, Watanabe A, Muramatsu K, Ogane S, Murayama M, Sekine R, Nakata E, Fujimoto Y. Bisphosphonate-related osteonecrosis of jaw (BRONJ) in Japanese population: a case series of 13 patients at our clinic. THE BULLETIN OF TOKYO DENTAL COLLEGE 2015; 54:117-25. [PMID: 23903583 DOI: 10.2209/tdcpublication.54.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) affects quality of life and is an important problem for dentists. A Japanese position paper on BRONJ was published in 2010. The purpose of this study was to review clinical data on the treatment of BRONJ obtained at the Clinic of Oral and Maxillofacial Surgery, Tokyo Dental College, Chiba Hospital to further our understanding of this disease. A total of 13 patients (6 men and 7 women) were included. All the patients included in this study had received Bisphosphonate (BP) therapy and had BRONJ. Five of them (38.5%) had received oral BP therapy for osteoporosis, while the remaining 8 (61.5%) had received parenteral BP therapy for bone metastases from breast or prostate cancer. Osteoporosis patients were treated with risedronate or alendronate. Breast or prostate cancer patients were treated with zoledronate. Two patients with rheumatoid arthritis were treated with corticosteroid. Three patients had diabetes mellitus. Eleven patients were treated with antibiotics, while 5 underwent surgical treatment. Discontinuation of BP was recorded in 7 patients during dental treatment. Sequestration was observed in 6 patients during an 11-month follow-up. Eventually, healing and improvement of the oral mucosa were observed in 3 patients. The current standard treatment for BRONJ does not always provide good results. It is necessary to accumulate further clinical data to establish more effective treatment strategies for BRONJ.
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Affiliation(s)
- Takeshi Nomura
- Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 1-2-2 Masago, Mihama-ku, Chiba 261-8502, Japan.
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72
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Spanou A, Lyritis GP, Chronopoulos E, Tournis S. Management of bisphosphonate-related osteonecrosis of the jaw: a literature review. Oral Dis 2015; 21:927-36. [PMID: 25732104 DOI: 10.1111/odi.12333] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/08/2014] [Accepted: 02/24/2015] [Indexed: 12/31/2022]
Abstract
Osteonecrosis of the jaw (ONJ) is a serious side effect of bisphosphonate use in patients with osteoporosis, Paget's disease, hypercalcemia of malignancy, metastatic bone disease and multiple myeloma, although recently this complication has also been reported in patients under non-bisphosphonate medication, such as denosumab and bevacizumab. The occurrence of ONJ is higher in oncology patients treated with high-dose iv bisphosphonates than in osteoporosis patients treated with oral bisphosphonates. Although multiple hypotheses have been proposed, the exact pathogenic mechanism of ONJ still remains unclear. As treatment protocols based on randomized controlled trials (RCTs) do not exist, we critically reviewed the existing data concerning the management of bisphosphonate-related osteonecrosis of the jaw, including the most recent data for the use of teriparatide and hyperbaric oxygen.
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Affiliation(s)
- A Spanou
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece
| | - G P Lyritis
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece
| | - E Chronopoulos
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece.,2nd Orthopaedic Department, Konstantopoulion Hospital, University of Athens, Athens, Greece
| | - S Tournis
- Laboratory for Research of the Musculoskeletal System 'Th. Garofalidis', Medical School, KAT Hospital, University of Athens, Athens, Greece
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73
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Kolokythas A, Karras M, Collins E, Flick W, Miloro M, Adami G. Salivary Biomarkers Associated With Bone Deterioration in Patients With Medication-Related Osteonecrosis of the Jaws. J Oral Maxillofac Surg 2015; 73:1741-7. [PMID: 25889372 DOI: 10.1016/j.joms.2015.03.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 03/06/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to investigate the use of saliva as a medium for the identification of biomarkers associated with bone resorption and formation. The authors hypothesized that biomarkers, such as N-telopeptide of type I collagen (NTX) and bone-specific alkaline phosphatase (B-AP), could be identified in saliva. They further hypothesized that there would be a difference between these biomarkers in the saliva of patients with medication-relation osteonecrosis of the jaws (MRONJ) and those who have no risk factors for the development of MRONJ. PATIENTS AND METHODS This case-and-control study compared 2 salivary biomarkers, NTX and B-AP, in a group of patients with MRONJ and a control group. The predictor variable was the presence or absence of the disease (MRONJ or control group); the outcome variables were the levels of the 2 salivary biomarkers, NTX and B-AP. Saliva samples from 20 patients with a diagnosis of MRONJ and 14 control participants who were comparable to the study group with no history of antiresorptive medication use were collected. The saliva samples were analyzed using 2 commercially available assays for NTX and B-AP to evaluate for levels of each marker. A 2-tailed t test for 2 groups of unequal distribution was used for statistical analysis, with P values less than .05 considered statistically. RESULTS The 2 biomarkers, NTX and B-AP, were detected in saliva samples from the MRONJ and control groups. A statistically significant difference was found in the levels of NTX in saliva of patients with MRONJ compared with the control participants (P = .0067). CONCLUSIONS In this exploratory study, the 2 bone deterioration biomarkers (NTX and B-AP) were detected in saliva. There was a statistical difference in the levels of salivary NTX between patients with MRONJ and controls. Saliva evaluation could provide a novel method to detect, diagnose, stage, and potentially guide treatment decisions and monitor outcomes for patients with MRONJ in the future.
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Affiliation(s)
- Antonia Kolokythas
- Associate Professor, Program Director, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL.
| | - Maria Karras
- Dental Student, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL
| | - Edward Collins
- Former Chief Resident, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL
| | - William Flick
- Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL
| | - Michael Miloro
- Professor and Head, Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL
| | - Guy Adami
- Associate Professor, Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago, College of Dentistry and the University of Illinois Hospitals and Health Science Center, Chicago, IL
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Treatment perspectives for medication-related osteonecrosis of the jaw (MRONJ). J Craniomaxillofac Surg 2015; 43:290-3. [DOI: 10.1016/j.jcms.2014.11.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/13/2014] [Accepted: 11/13/2014] [Indexed: 11/21/2022] Open
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75
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Kim YH, Lee HK, Song SI, Lee JK. Drug holiday as a prognostic factor of medication-related osteonecrosis of the jaw. J Korean Assoc Oral Maxillofac Surg 2014; 40:206-10. [PMID: 25368832 PMCID: PMC4217272 DOI: 10.5125/jkaoms.2014.40.5.206] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/18/2014] [Accepted: 07/24/2014] [Indexed: 11/09/2022] Open
Abstract
Objectives To identify post-treatment prognostic factors for medication-related osteonecrosis of the jaw (MRONJ). Materials and Methods We evaluated 54 MRONJ patients who visited the Department of Dentistry, Ajou University Hospital, from May 2007 to March 2014. Twenty-one patients were surgically managed with debridement or sequestrectomy and 33 patients were conservatively managed using antibiotics. Correlations of age, sex, stage, bisphosphonate duration and type, and drug holiday with the prognosis of MRONJ were investigated. Correlations were verified by logistic regression analysis and t-tests with a significance level of 0.05. Results Clinical outcomes were evaluated on the basis of both clinical and radiographic findings. Twelve out of 21 surgically managed patients showed a favorable prognosis and nine patients relapsed. Thirty-one of the 33 conservatively managed patients showed no specific change in prognosis, and two patients worsened. Statistical analyses of the conservative management group did not reveal any correlation of the above factors with the prognosis of conservative management. Drug holiday was the only prognostic factor in the surgical management group (P=0.031 in logistic regression analysis, P=0.004 in t-test). Conclusion Drug holiday is a prognostic factor in the surgical management of MRONJ. Because the drug holiday in the patients of the poor prognosis group occurred 1.5 to 4 months prior to surgical management, we recommend a drug holiday more than 4 months before surgery.
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Affiliation(s)
- Yoon Ho Kim
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
| | - Ho Kyung Lee
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
| | - Seung Il Song
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
| | - Jeong Keun Lee
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
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76
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Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, O'Ryan F. American Association of Oral and Maxillofacial Surgeons Position Paper on Medication-Related Osteonecrosis of the Jaw—2014 Update. J Oral Maxillofac Surg 2014; 72:1938-56. [DOI: 10.1016/j.joms.2014.04.031] [Citation(s) in RCA: 1587] [Impact Index Per Article: 158.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 04/21/2014] [Indexed: 12/14/2022]
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77
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Carlson ER. Response to the Letter to the Editor. J Oral Maxillofac Surg 2014; 72:1641-2. [DOI: 10.1016/j.joms.2014.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 10/24/2022]
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78
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Bedogni A, Fedele S, Bedogni G, Scoletta M, Favia G, Colella G, Agrillo A, Bettini G, Di Fede O, Oteri G, Fusco V, Gabriele M, Ottolenghi L, Valsecchi S, Porter S, Petruzzi M, Arduino P, D’Amato S, Ungari C, Fung Polly PL, Saia G, Campisi G. Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease. Br J Oral Maxillofac Surg 2014; 52:603-8. [PMID: 24856927 DOI: 10.1016/j.bjoms.2014.04.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
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Abstract
Bisphosphonates and other more recent antiresorptive agents are potent inhibitors of osteoclast function and osteoclast-mediated bone resorption. As such, they have been effectively utilised to reduce skeletally related events and improve the quality of life of patients with osteoporosis and malignant osteolytic disease. Despite these benefits, osteonecrosis of the jaw continues to be a worrisome complication in a small subset of patients receiving these drugs.
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Affiliation(s)
- Salvatore Ruggiero
- New York Centre for Oral and Maxillofacial Surgery, 99 Holst Drive West, Huntington, New York, 117 43, USA
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80
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Abstract
Nitrogen-containing and non-nitrogen-containing bisphosphonates have been implicated in the development of osteonecrosis of the jaw (ONJ), a condition termed bisphosphonate-related OHJ. Other antiresorptive drugs have been implicated in the development of OHJ, hence the new term antiresorptive drug-related ONJ. The underlying pathogenesis remains unclear, and no definite diagnosis or cure has been established for this debilitating condition. This article reviews some of the most common antiresorptive drugs with their associated risks of ONJ and the current understanding of the pathogenesis ONJ, and summarizes current clinical guidelines.
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Affiliation(s)
- Jettie Uyanne
- Division of Oral and Maxillofacial Surgery, Herman Ostrow School of Dentistry of USC, 925 West 34th Street, Los Angeles, CA 90089-0641, USA; Division of Oral and Maxillofacial Surgery, Harbor UCLA, 1000 West Carson Street, Torrance, CA 90509, USA.
| | - Colonya C Calhoun
- Division of Oral and Maxillofacial Surgery, Harbor UCLA, 1000 West Carson Street, Mailbox #19, Torrance, CA 90509, USA; Charles R. Drew University, Los Angeles, CA, USA
| | - Anh D Le
- Division of Oral and Maxillofacial Surgery, Herman Ostrow School of Dentistry of USC, 925 West 34th Street, Los Angeles, CA 90089-0641, USA; Department of Oral and Maxillofacial Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, Penn Medicine Hospital of the University of Pennsylvania, 240 South 40th Street, Philadelphia, PA 19104-6030, USA
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81
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Carlson ER, Schlott BJ. Anti-resorptive osteonecrosis of the jaws: facts forgotten, questions answered, lessons learned. Oral Maxillofac Surg Clin North Am 2014; 26:171-91. [PMID: 24630868 DOI: 10.1016/j.coms.2014.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Osteonecrosis of the jaws associated with bisphosphonate and other anti-resorptive medications (ARONJ) has historically been a poorly understood disease process in terms of its pathophysiology, prevention and treatment since it was originally described in 2003. In association with its original discovery 11 years ago, non-evidence based speculation of these issues have been published in the international literature and are currently being challenged. A critical analysis of cancer patients with ARONJ, for example, reveals that their osteonecrosis is nearly identical to that of cancer patients who are naive to anti-resorptive medications. In addition, osteonecrosis of the jaws is not unique to patients exposed to anti-resorptive medications, but is also seen in patients with osteomyelitis and other pathologic processes of the jaws. This article represents a review of facts forgotten, questions answered, and lessons learned in general regarding osteonecrosis of the jaws.
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Affiliation(s)
- Eric R Carlson
- Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, University of Tennessee Cancer Institute, 1930 Alcoa Highway, Knoxville, TN 37920, USA.
| | - Benjamin J Schlott
- Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, University of Tennessee Cancer Institute, 1930 Alcoa Highway, Knoxville, TN 37920, USA
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82
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Campisi G, Fedele S, Fusco V, Pizzo G, Di Fede O, Bedogni A. Epidemiology, clinical manifestations, risk reduction and treatment strategies of jaw osteonecrosis in cancer patients exposed to antiresorptive agents. Future Oncol 2014; 10:257-75. [PMID: 24490612 DOI: 10.2217/fon.13.211] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
ABSTRACT: Osteonecrosis of the jaws (ONJ) is an adverse side event of bisphosphonates and denosumab, antiresorptive agents that effectively reduce the incidence of skeletal-related events in patients with metastatic bone cancer and multiple myeloma. Available data suggest that 0–27.5% of individuals exposed to antiresorptive agents can develop ONJ. There is increasing evidence that avoidance of surgical trauma and infection to the jawbones can minimize the risk of ONJ, but there are still a significant number of individuals who develop ONJ in the absence of these risk factors. Bone necrosis is almost irreversible and there is no definitive cure for ONJ with the exclusion, in certain cases, of surgical resection. However, most ONJ individuals are affected by advanced incurable cancer and are often managed with minimally invasive nonsurgical interventions in order to control jawbone infections and painful symptoms. This article summarizes current knowledge of ONJ epidemiology, manifestations, risk-reduction and therapeutic strategies. Further research is needed in order to determine individual predisposition to ONJ and clarify the effectiveness of available treatments.
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Affiliation(s)
- Giuseppina Campisi
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Stefano Fedele
- University College London, UCL Eastman Dental Institute, & NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Vittorio Fusco
- Unit of Oncology, Department of Oncology & Hematology, Azienda Ospedaliera di Alessandria (City Hospital), Alessandria, Italy
| | - Giuseppe Pizzo
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Olga Di Fede
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Alberto Bedogni
- Unit of Oral & Maxillofacial Surgery, Department of Surgery, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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83
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Carlson ER. Management of antiresorptive osteonecrosis of the jaws with primary surgical resection. J Oral Maxillofac Surg 2013; 72:655-7. [PMID: 24480762 DOI: 10.1016/j.joms.2013.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/05/2013] [Accepted: 12/05/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Eric R Carlson
- Professor and Kelly L. Krahwinkel Chairman, Director of Residency Program, Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center; Director, Oral/Head and Neck Oncologic Surgery Fellowship Program, University of Tennessee Cancer Institute, Knoxville, TN.
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84
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Iglesias JE, Salum FG, Figueiredo MA, Cherubini K. Important aspects concerning alendronate-related osteonecrosis of the jaws: a literature review. Gerodontology 2013; 32:169-78. [PMID: 24256517 DOI: 10.1111/ger.12093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To conduct a literature review on sodium alendronate, focusing on osteonecrosis of the jaws, a serious potential side effect. BACKGROUND Sodium alendronate is a bisphosphonate that is widely used for the treatment of osteopenia, osteoporosis and Paget's disease. Like other bisphosphonates, it inhibits bone resorption by inactivating osteoclasts. Alendronate has evident benefits in the treatment of these diseases, but it is associated with jaw osteonecrosis, although less frequently compared with intravenous bisphosphonates. Therefore, some preventive measures should be taken to avoid this side effect. MATERIAL AND METHODS We reviewed the literature regarding the pharmacological aspects, mechanism of action, indications of use and side effects of sodium alendronate, as well as the management of patients under this therapy. CONCLUSION The benefits of sodium alendronate are scientifically proven, but a serious adverse effect is osteonecrosis. Therefore, it is crucial to prepare the oral cavity before bisphosphonate therapy, providing a careful dental evaluation and all needed dental treatment.
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Affiliation(s)
- Julia E Iglesias
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda G Salum
- Postgraduate Program of Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria A Figueiredo
- Postgraduate Program of Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Karen Cherubini
- Postgraduate Program of Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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85
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Campisi G, Bedogni A, Di Fede O, Vescovi P, Fusco V, Lo Muzio L. Osteonecrosi dei mascellari associata a bisfosfonati, denosumab e farmaci anti-angiogenetici nei pazienti oncologici e osteoporotici: diagnosi e terapia. DENTAL CADMOS 2013. [DOI: 10.1016/s0011-8524(13)70099-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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86
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Peacock ZS, Aghaloo T, Bouloux GF, Cillo JE, Hale RG, Le AD, Lee JS, Kademani D. Proceedings from the 2013 American Association of Oral and Maxillofacial Surgeons Research Summit. J Oral Maxillofac Surg 2013; 72:241-53. [PMID: 24438595 DOI: 10.1016/j.joms.2013.09.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 11/24/2022]
Abstract
The American Association of Oral and Maxillofacial Surgeons, the Oral and Maxillofacial Surgery Foundation, and the International Association of Oral and Maxillofacial Surgeons sponsored the fifth research summit, which convened on May 2 and 3 in Rosemont, Illinois. The Research Summits are convened biennially to facilitate the discussion and collaboration of oral and maxillofacial surgeons with clinical and basic science researchers in fields affecting the specialty. The goal is to advance the field of oral and maxillofacial surgery through exposure and education in topics that ultimately benefit the oral and maxillofacial surgical patient. This edition of the research summit included the topics of robotic surgery and antiresorptive-related osteonecrosis of the jaws (ARONJ). Most importantly, this research summit saw the development of research interest groups (RIGs) in the fields of anesthesia, maxillofacial oncology and reconstructive surgery, obstructive sleep apnea and orthognathic surgery, temporomandibular joint surgery, and trauma. These RIGs developed specific research goals with a plan to continue working on potential projects at the AAOMS Clinical Trials Course on May 7 to 9, 2013 at the University of Michigan in Ann Arbor. The summit program was developed by the AAOMS Committee on Research Planning and Technology Assessment. The charge of the committee is to encourage and promote research within the specialty and to encourage interdisciplinary collaboration. The research summit serves as a platform for oral and maxillofacial surgeons to lead the goal of advancement of research relevant to the specialty. This article provides an overview of the presentations that were made in the sessions on robotic surgery and ARONJ. The research summit keynote address and two additional presentations on patient registries are summarized and updates from the RIGs that were formed at the 2013 research summit are highlighted.
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Affiliation(s)
- Zachary S Peacock
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
| | - Tara Aghaloo
- Associate Professor, Division of Oral and Maxillofacial Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Gary F Bouloux
- Associate Professor, Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine
| | - Joseph E Cillo
- Program Director and Director of Research, Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Robert G Hale
- Commander, Dental and Trauma Detachment, US Army Institute of Surgical Research, Fort Sam Houston, TX
| | - Anh D Le
- Chair and Norman Vine Endowed Professor of Oral Rehabilitation, Department of Oral and Maxillofacial Surgery/Pharmacology, University of Pennsylvania, Philadelphia, PA
| | - Janice S Lee
- Deputy Clinical Director, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Deepak Kademani
- Associate Professor, Division of Oral and Maxillofacial Surgery, University of Minnesota, Minneapolis, MN
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Intraoperative efficiency of fluorescence imaging by Visually Enhanced Lesion Scope (VELscope) in patients with bisphosphonate related osteonecrosis of the jaw (BRONJ). J Craniomaxillofac Surg 2013; 42:e157-64. [PMID: 24011463 DOI: 10.1016/j.jcms.2013.07.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 06/04/2013] [Accepted: 07/31/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The purpose of this study was to determine the potential of tissue fluorescence imaging by using Visually Enhanced Lesion Scope (VELscope) for the detection of osteonecrosis of the jaw induced by bisphosphonates (BRONJ). METHODS We investigated 20 patients (11 females and 9 males; mean age 74 years, standard deviation ± 6.4 years), over a period of 18 month with the diagnosis of BRONJ in this prospective cohort study. All patients received doxycycline as a fluorescending marker for osseous structures. VELscope has been used intraoperatively using the loss of fluorescence to detect presence of osteonecrosis. Osseous biopsies were taken to confirm definite histopathological diagnosis of BRONJ in each case. RESULTS Diagnosis of BRONJ was confirmed for every patient. In all patients except one, VELscope was sufficient to differentiate between healthy and necrotic bone by visual fluorescence retention (VFR) and visual fluorescence loss (VFL). 19 cases out of a total of 20 showed no signs of recurrence of BRONJ during follow-up (mean 12 months, range 4-18 months). CONCLUSION VELscope examination is a suitable tool to visualize necrotic areas of the bone in patients with bisphosphonate related osteonecrosis of the jaw. Loss of fluorescence in necrotic bone areas is useful intraoperatively as a tool for fluorescence-guided bone resection with relevant clinical interpretation.
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88
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Ruggiero SL. An office-based approach to the diagnosis and management of osteonecrosis. Atlas Oral Maxillofac Surg Clin North Am 2013; 21:167-173. [PMID: 23981492 DOI: 10.1016/j.cxom.2013.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore/LIJ School of Medicine, 270-05 76th Avenue, New Hyde Park, Hempstead, NY 11040, USA.
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