Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus

Biomaterials and therapeutic strategies designed for tooth extraction socket healing

Tooth extraction is the most commonly performed oral surgical procedure, with a wide range of clinical indications. The oral cavity is a complex microenvironment, influenced by oral movements, salivary flow, and bacterial biofilms. These factors can contribute to delayed socket healing and the onset of post-extraction complications, which can burden patients' esthetic and functional rehabilitation. Achieving effective extraction socket healing requires a multidisciplinary approach. Recent advancements in materials science and bioengineering have paved the way for developing novel strategies. This review outlines the fundamental healing processes and cellular-molecular interactions involved in the healing of extraction sockets. It then delves into the current landscape of biomaterials for socket healing, highlighting emerging strategies and potential targets that could transform the treatment paradigm. Building upon this foundation, this review also presents future directions and identifies challenges associated with the clinical application of biomaterials for extraction socket healing.

Risk factors for osteonecrosis of the jaw in patients with chronic kidney disease: a nested case-control study

Osteonecrosis of the jaw (ONJ) is a severe disease leading to decreased quality of life, but risk factors for ONJ in chronic kidney disease (CKD) patients remain unclear. We conducted a nested case-control study using a large Japanese administrative database to investigate. CKD patients were identified based on estimated glomerular filtration rate (eGFR) measurements, and ONJ cases were identified using ICD-10 codes and diagnostic terms. Controls were matched 1:4 by age and sex. Among 597 026 CKD patients, 75 ONJ cases were identified during a median follow-up of 2.9 yr (incidence rate: 3.27 per 100 000 patient-years). A total of 375 patients (250 males, 66.7%) with a median age of 72 yr (interquartile range (IQR), 64-78) were included after matching controls. The use of bisphosphonates and denosumab for tumor-related disorders in the case group was significantly higher compared to the control group. There was no significant association between kidney functions and the ONJ risk. Multivariate analysis revealed that anti-resorptive drugs for tumor-related disorders [odds ratio (OR): 74.74, 95% confidence interval (CI): 8.81-634.39, p<.001] and oral corticosteroids (OR: 13.23, 95% CI: 3.34-52.33, p<.001) were significantly associated with increased ONJ risk, while anti-resorptive drugs for osteoporosis and injectable corticosteroid use were not. Other relevant factors such as diabetes, liver disease, anabolic drugs, and radiation therapy did not have a significant association with ONJ risk. When stratified by indications for bisphosphonate use (known to be eliminated by renal excretion), bisphosphonate use for tumor-related disorders showed a significant association with ONJ risk (OR: 27.80, 95% CI: 2.47-313.29, p<.01), while bisphosphonates use for osteoporosis did not (OR: 0.74, 95% CI: 0.19-2.92, p=.67). These findings suggest that anti-resorptive drugs for tumor-related disorders and oral corticosteroids are associated with ONJ risk in CKD patients. Heightened surveillance may be necessary for CKD patients receiving these treatments to prevent or detect ONJ early.

Antiresorptive therapy in combination with radiation results in enhanced risk for necrosis and associated complicatifions

OBJECTIVE

Patients exposed to a combination of antiresorptive medication and radiotherapy of the head and neck area developing necrosis of the jaw in the course of treatment are extremely rare. Therefore, the aim of this study was to identify the outcome and complications in this highly vulnerable patient cohort.

STUDY DESIGN

Seventeen patients who received both antiresorptive treatment and radiotherapy (medication-related osteonecrosis of the jaw/osteoradionecrosis = the [MRONJ/ORN] group) in the head and neck area were enrolled in this study. Included patients were treated in our department between 2005 and 2022. Four hundred twenty-four patients with MRONJ (the MRONJ group) and 138 patients with ORN of the jaw were enrolled as two control groups (the ORN group). Demographic data, lesion localization, date of primary diagnosis, clinical symptoms, type of therapy (surgical or non-surgical), details on antiresorptive treatment, outcome, and complications were recorded.

RESULTS

Pathological fractures, continuity resection, and recurrence appear more often in patients who receive a combination of antiresorptive treatment and radiotherapy in the head and neck area compared with patients undergoing only one of these treatments. There was a statistically significant difference (P < .001) between the MRONJ/ORN group and the MRONJ group and the MRONJ/ORN group and the ORN group considering recurrence, fracture, and continuity resection. Patients with ORN combined with MRONJ have a 4-times higher risk for developing recurrence compared with patients with MRONJ and a 1.5-times higher risk for recurrence compared with patients with ORN. Jaw fracture and continuity resection appear more often in patients with MRONJ/ORN.

CONCLUSIONS

Patients under antiresorptive therapy in combination with radiation therapy in the head and neck area have a higher risk for developing complications in case of osteonecrosis of the jaw. Therefore, a strict follow-up care schedule is highly recommended.

Medication-Related Osteonecrosis of the Jaw: Bibliometric Analysis from 2003 to 2023

Medication-related osteonecrosis of the jaw (MRONJ) is a serious condition associated with the use of antiresorptive and antiangiogenic medications. Despite extensive research, the pathophysiology of MRONJ remains poorly understood. Bibliometric analysis provides insights into the academic impact of research, helping identify influential works and emerging trends in this field. This study employed a bibliometric analysis of MRONJ publications indexed in Web of Science from 2003 to 2023. The analysis included English-language articles and utilized the VOSviewer, R Studio Bibliometrix package, and Graphpad to evaluate citation counts, publication trends, and collaboration patterns. This study unveils the current situation of the MRONJ research, addressing well-recognized safety issues of antiresorptive and antiangiogenic agents. Our findings may suggest that the overall trend of the MRONJ research continues to evolve and is not likely to reach its peak or plateau yet. We believe that our work will help to identify gaps in the literature and future research directions, contributing to a better understanding of MRONJ management.

Polyphenols and Functionalized Hydrogels for Osteoporotic Bone Regeneration

Osteoporosis induces severe oxidative stress and disrupts bone metabolism, complicating the treatment of bone defects. Current therapies often have side effects and require lengthy bone regeneration periods. Hydrogels, known for their flexible mechanical properties and degradability, are promising carriers for drugs and bioactive factors in bone tissue engineering. However, they lack the ability to regulate the local pathological environment of osteoporosis and expedite bone repair. Polyphenols, with antioxidative, anti-inflammatory, and bone metabolism-regulating properties, have emerged as a solution. Combining hydrogels and polyphenols, polyphenol-based hydrogels can regulate local bone metabolism and oxidative stress while providing mechanical support and tissue adhesion, promoting osteoporotic bone regeneration. This review first provides a brief overview of the types of polyphenols and the mechanisms of polyphenols in facilitating adhesion, antioxidant, anti-inflammatory, and bone metabolism modulation in modulating the pathological environment of osteoporosis. Next, this review examines recent advances in hydrogels for the treatment of osteoporotic bone defects, including their use in angiogenesis, oxidative stress modulation, drug delivery, and stem cell therapy. Finally, it highlights the latest research on polyphenol hydrogels in osteoporotic bone defect regeneration. Overall, this review aims to facilitate the clinical application of polyphenol hydrogels for the treatment of osteoporotic bone defects.

Treatment for osteoporosis and risk of osteonecrosis of the jaw among female patients in the United Kingdom Clinical Practice Research Datalink

Osteonecrosis of the jaw (ONJ) is an adverse effect of antiresorptives. Among female patients treated for osteoporosis, ONJ risk was threefold higher after 2-3 years of treatment and eightfold after 10 years compared with past use. Absolute risks remained low (~ 0.05% after 5 years) and diminished after discontinuation.

PURPOSE

Osteonecrosis of the jaw (ONJ) is a rare adverse effect of antiresorptive drug use; however, the magnitude of risk in osteoporosis patients has not been clearly described.

METHODS

We conducted a cohort study among cancer-free female patients aged 40-89 with, or at risk for, osteoporosis in United Kingdom Clinical Practice Research Datalink (CPRD) Aurum. We followed patients from first osteoporosis treatment until first of osteonecrosis diagnosis, age 90, record end, or other prespecified censoring event, and accumulated person-time by osteoporosis treatment. ONJ cases were selected from CPRD Aurum and linked Hospital Episode Statistics data using an algorithm and manual review. We estimated incidence rates (IR) of ONJ by current treatment type and post discontinuation. We conducted a nested case-control analysis to further describe risk by cumulative dose and duration of antiresorptive therapies.

RESULTS

Among 467,654 eligible patients, there were 208 ONJ cases. IR among patients currently treated with antiresorptives (primarily alendronate) was 1.2 (95% confidence interval [CI] 1.0-1.4) per 10,000 person-years. Compared with past use of antiresorptives, odds ratios of ONJ were 3.0 (95% CI 1.5-5.7) after 2-3 years of treatment and 8.1 (95% CI 4.4-15) after 10 years. However, absolute risks remained low (~ 0.05% after 5 years and ~ 0.18% after 10 years) and elevated risks diminished to near zero within 6 to 9 months of discontinuation.

CONCLUSION

Risk of ONJ increased after 2-3 years of treatment with antiresorptives; however, the absolute risk was low and returned to baseline shortly after treatment discontinuation.

Zoledronic acid as adjuvant therapy in neovascular age-related macular degeneration: a randomised controlled pilot study

AIMS

To assess the feasibility of a study protocol for a randomised controlled trial of zoledronic acid (ZA) as adjuvant therapy for neovascular age-related macular degeneration (nAMD).

METHODS

In this 1-year, randomised, double-blinded, placebo-controlled pilot study, nAMD patients were allocated 1:1 to receive intravenous ZA 5 mg or placebo at baseline and after 6 months in addition to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy following a treat-and-extend regimen. Bevacizumab was the first-line anti-VEGF drug, but eyes with refractory nAMD were switched to aflibercept. The primary outcome was mean change in best-corrected visual acuity (BCVA).

RESULTS

40 participants enrolled in the study, with 20 allocated to each treatment group. 38 participants received both study infusions, and all participants completed the final assessment. Mean (SD) change in BCVA was 7.5 (9.5) letters in the ZA group and -0.5 (11.5) letters in the control group; the between-group difference was 8.0 letters (95% CI: 1.5 to 15.0 letters). There were no between-group differences in mean change in central retinal thickness, refractory nAMD proportion or mean number of injections.

CONCLUSION

It is feasible to conduct a randomised controlled trial of ZA as adjuvant therapy for nAMD in terms of recruitment and adherence to the pilot study protocol. We found a possible visual benefit of ZA that is worth further investigation. To clarify the relationship between ZA and the need for intravitreal injections, we recommend amending the protocol by omitting switching of the anti-VEGF drug. Due to the limited sample size of the pilot study, the estimates of treatment effect are not meant to be confirmatory and should be interpreted with caution.

TRIAL REGISTRATION NUMBER

2019-001492-37 (EudraCT), 04304755 (NCT).

Prevention of medication-related osteonecrosis of the jaw: institutional insights from a retrospective study

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a serious, debilitating condition of the jaw bones. Dental extraction is the most significant independent risk factor for MRONJ. This interim study aimed to evaluate the demographics, medical data and outcomes of patients at risk for MRONJ who underwent dental extractions in a dedicated MRONJ clinic following a risk reduction protocol at a large public dental clinic in New South Wales Health.

METHODS

A retrospective study analysed demographic and clinical data of patients at risk for MRONJ who underwent dental extractions between March 2020 and April 2024.

RESULTS

Data from 329 at-risk patients who underwent 836 dental extractions were included. Most patients were women (75.1%) with a median age of 74 years (IQR 67-80). The primary indication for medications was osteoporosis (85.4%), with Denosumab being the most frequently prescribed (66.9%). Eighteen patients (5.5%) developed MRONJ at 8 weeks of follow-up. Patients categorized as high-risk had a higher incidence of MRONJ (72.2%) compared to the low-risk group (22.2%).

CONCLUSION

This study is the first retrospective audit carried out after implementing preventive protocols in this dedicated MRONJ clinic. The higher incidence of MRONJ in patients classified as 'high risk' underscores the importance of considering individual risk factors in their treatment.

Osteoprotective effect of Achyranthes bidentata root extract on osteoporotic rats: a systematic review and meta-analysis

CONTEXT

Achyranthes bidentata Blume (ABB), a plant of Amaranthaceae family, has been one of the more commonly used phytomedicine remedies for thousands of years, and recent studies have highlighted the efficacy of its extracts in the treatment of osteoporosis. Nonetheless, a thorough analysis of its benefits is currently absent.

OBJECTIVE

This meta-analysis assessed the effects of ABB root extract (ABBRE) on osteoporotic rats and provides a rationale for future clinical studies.

METHODS

Searches were conducted in seven different Chinese and English databases, and the search period was from their establishment to January 2024. This study was registered in PROSPERO (CRD42023418917). Selected research regarding the ABBRE treatment of osteoporotic rats, and the corresponding research has distinctly reported outcomes, and the data on the bone mineral density (BMD), bone histomorphometrics, biomechanical parameters, and bone biochemical markers of osteoporotic rats can be extracted.

RESULTS

Through screening, 11 studies met the eligibility requirements for inclusion, in which 222 animals were studied. The treatment group with ABBRE exhibited increased bone mineral density (standardized mean difference [SMD] = 1.64, 95% CI = 0.52 to 2.77). Based on subgroup analysis, the greatest increase in bone mineral density was observed when the dose of ABBRE was ≤ 400 mg/kg/day and the duration of treatment was ≤ 12 weeks.

CONCLUSIONS

ABBRE is a phytomedicine that can effectively promote the enhancement of bone mineral density and ease osteoporosis. It can be developed into a new alternative therapy by conducting experiments and clinical studies on larger samples.

Optimal Management of Osteoporosis in the Spinal Cord (Injury) Population

Spinal cord injury (SCI) leads to significant bone loss resulting in osteoporosis and an increased risk of fractures below the level of injury. It is imperative to screen for osteoporosis in all individuals with SCI starting immediately after the acute injury. Although data are limited, clinicians are encouraged to discuss preventative treatment in the acute SCI period and to treat osteoporosis when diagnosed.

Diagnosis and Management of Atypical Femoral Fractures and Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

Anti-osteoporosis treatments reduce fracture risk but maybe associated with rare adverse events with long-term use such as atypical femoral fractures (AFFs) and medication-related osteonecrosis of the jaw (MRONJ). AFFs are rare but more likely with prolonged bisphosphonate use, whereas MRONJ incidence is higher in cancer patients on high-dose antiresorptive therapy. Following diagnosis, effective treatment options are available to manage both of these rare complications. An individualized treatment approach is advised with close monitoring.

Education and Communication on the Topic of Osteonecrosis of the Jaw When Taking Bone-Stabilizing Drugs

OBJECTIVES

The aim of this study was to analyze the communication between doctors and patients who were taking bone-stabilizing medication and in rare cases developed osteonecrosis of the jaw as a result.

MATERIAL AND METHODS

A standardized questionnaire recorded deficits based on patient experiences. These data were used to develop solution strategies for improving doctor-patient communication and the benefit-risk assessment of medication use.

RESULTS

Most patients were satisfied with the information provided by their doctor; however, one in three (29.8%) were not informed about possible side effects, and a quarter (24.6%) only found out about osteonecrosis of the jaw through their own research. Only half (45.7%) were asked about risk factors, and most information materials were rated poorly. The diagnosis took an average of 18.7 months, with many (47.8%) consulting a doctor only when they experienced pain. Quality of life was severely impaired, with daily pain, physical limitations, and negative effects on mental health. About a third (35.3%) reported that their quality of life had deteriorated significantly.

CONCLUSIONS

Further research into patient education is necessary. Web-based information brochures, improved follow-up care, and close cooperation with dentists are required. The use of a running sheet, such as the AGSMO running sheet, for individual risk assessment of osteonecrosis of the jaw is recommended. Patients undergoing treatment with bone-stabilizing medication should be monitored closely. Education about osteonecrosis of the jaw must be continued, and the medical profession must be confronted with it.

Single-cell RNA sequencing reveals multiple immune cell subpopulations promote the formation of abnormal bone microenvironment in osteoporosis

With the aging of the population, the incidence of osteoporosis (OP) is on the rise, but the ecology of immune cell subpopulations in OP is poorly understood. Therefore, identifying cell subpopulations involved in promoting the development of OP may facilitate the development of new treatments. Based on bioinformatics analysis, we constructed a single-cell landscape of the OP microenvironment and identified immune cell subpopulations in OP to further explore the role of different subpopulations in the abnormal bone microenvironment. Among macrophages (Mac), the Mac_OLR1 subpopulation has an M1-like phenotype and significantly activates cytokine and osteoclast differentiation pathways, interacting with osteoclasts via the HBEGF-CD9 axis. In neutrophils (Neut), the Neut_RSAD2 subpopulation significantly activated cytokine and osteoclast differentiation pathways and had a high neutrophil extracellular trap (NET) score, and H1FX was identified as its potential regulator. In effector memory T (Tem) cells, the Tem_CCL4 subpopulation significantly activated osteoclast differentiation and immune inflammation-related pathways and highly expressed proinflammatory molecules such as CCL4, CCL4L2, CCL5 and IFNG. In B cells, the abundance of the B_ACSM3 subpopulation was significantly increased in the OP group and the osteoclast differentiation pathway was significantly activated, and MYB was identified as its potential regulator. In summary, we identified several immune cell subpopulations that may be involved in promoting the formation of OP, further identified the transcription factors that regulate these subpopulations, and speculated that the development of OP may be accompanied by immune inflammatory responses mediated by these subpopulations. These findings provide candidate molecules and cells for future OP research and may help facilitate the development of new therapies.

Is There an Ideal Concentration of Ozonized Oil for the Prevention and Modulation of Zoledronate-Induced Mandibular Osteonecrosis? A Study on Senescent Rats

This study aimed to identify whether there is an ideal concentration for applying ozonized oil (OZ) in the post-exodontic alveoli of senescent rats treated with zoledronate (ZOL). Thirty-five female rats, aged 18 months, were divided into five groups: ZOL; ZOL+OZ500; ZOL+OZ600; ZOL+OZ700; and SAL. The groups treated with ZOL, and other concentrations of OZ received applications at a dose of 100 μg/kg, while the SAL group received saline. After three weeks of ZOL application, the animals underwent extraction of the lower first molar. Subsequently, local therapies were initiated: group ZOL+OZ500 at 500 mEq/kg; ZOL+Z600 at 600 mEq/kg; and ZOL+OZ700 at 700 mEq/kg at baseline, and on days 2 and 4 post-operation. Euthanasia was performed on day 28. The microtomographic parameter of bone volume and histometric data on the area of neoformed bone (NFBT) showed the highest values for the ZOL+OZ600 group (p < 0.05). All OZ groups had smaller areas of non-vital bone than the ZOL group (p < 0.05). The clinical appearance of the operated region showed the alveoli covered with soft tissue, particularly in the OZ groups. All the tested concentrations of OZ were able to prevent and modulate MRONJ. As it presents a greater amount of NFBT, the concentration of 600 mEq/kg seems to be ideal.

The effect of cold atmospheric plasma on viability of osteoblasts and expression of RANKL and OPG genes in medium with bisphosphonates

Medication-related osteonecrosis of the jaw is a rare but severe complication with challenging treatment protocols. Cold atmospheric plasma (CAP) has shown promising effects in wound healing, cell proliferation and viability. This study investigated the effect of CAP on osteoblasts in a culture medium containing bisphosphonates. Pilot study was designed to determine the optimal setting of CAP. MG-63 cells were exposed to zoledronic acid at a concentration of 10 micromolar for 72 h. Study groups with the best MTT assay results, were chosen for assessing OPG and RANKL genes by RT-PCR. Cell viability was significantly higher in groups 9 kV.1 mm.90 s, 10 kV.1 mm.60 s, and 12 kV.1 mm.60 s (P < 0.05). Expression of RANKL in these groups was significantly lower than the positive control group (medium culture without zoledronic and plasma treatment) and higher than the BP group (culture with zoledronic without plasma treatment), except for the 12 kV.1 mm.60 s group, which did not differ significantly from the positive control group (P > 0.05). OPG decreased in all test groups compared to BP (p < 0.05), except for the 12 kV.1 mm.60 s group, which did not significantly differ from BP (P > 0.05). RANKL/OPG ratio in groups 9 kV.1 mm.90 s and 12 kV.1 mm.60 s significantly increased compared to BP (P < 0.05).CAP treatment may enhance the viability of osteoblasts exposed to bisphosphonates, increase their activity levels, enhance osteoclast activity, and improve bone turnover rates.

Extracellular vesicles from mouse bone marrow macrophages-derived osteoclasts treated with zoledronic acid contain miR-146a-5p and miR-322-3p, which inhibit osteoclast function

Medication-related osteonecrosis of the jaw (MRONJ) is an intractable form of osteonecrosis of the jaw that rarely occurs in patients using bone resorption inhibitors such as bisphosphonates (BPs). Then, extracellular vesicles (EVs) carry various signaling molecules, such as mRNAs, microRNAs (miRNAs), and proteins, and have attracted attention as intercellular communication tools. Recently, the role of EVs in communication between osteoclasts and surrounding bone cells has been confirmed. This study aimed to elucidate the effects of EVs derived from osteoclasts treated with zoledronic acid (ZA), one of the BPs on osteoclast function. EVs were isolated by ultracentrifugation of the culture supernatant of osteoclasts treated with ZA, and miRNAs were extracted from these EVs. Tartrate-resistant acid phosphatase staining of the ZA treated osteoclasts showed reduced osteoclastogenesis. In addition, pit assay showed that ZA significantly decreased the bone resorption capacity of osteoclasts. miRNA-seq analysis identified 11 upregulated and 5 downregulated differentially expressed genes (DEGs) in the miRNA of EVs derived from ZA-treated osteoclasts compared to EVs derived from osteoclasts not treated with ZA. qRT-PCR analysis confirmed the amount of these specific miRNAs, with miR-146a-5p, and miR-322-3p being significantly upregulated by ZA. Overexpression of miR-146a-5p in osteoclasts inhibited osteoclastogenesis and decreased the mRNA expression of osteoclast markers. In addition, Traf6 was identified as a candidate target gene of miR-146a-5p in several miRNA databases. Indeed, the overexpression of miR-146a-5p decreased the expression level of Traf6 in osteoclasts. Additionally, overexpression of miR-322-3p in the pre-osteoblast, MC3T3-E1 cells, resulted in a significant increase in the mRNA expression levels of Sp7. Our data indicate that BPs attenuate osteoclastogenesis by simultaneously altering the characteristics of osteoclast-derived EVs. Overexpression of miR-146a-5p and miR-322-3p influences osteoclast differentiation, and Traf6 is a target gene of miR-146a-5p. On the other hand, Overexpression of miR-322-3p affects osteoblast differentiation. We suggest that ZA-treated osteoclast-derived EVs may play an important role in osteoclast function and bone resorption.

Reduction of MRONJ risk after exodontia by virtue of ozone infiltration: A randomized clinical trial

INTRODUCTION

Exodontia is commonly considered as a risk factor for the development of medication-related osteonecrosis of the jaw (MRONJ) in individuals exposed to bone modifying agents. This study was aimed at assessing the efficiency and safety of a gaseous oxygen-ozone mixture as an adjuvant to a standard exodontia to reduce the risk of MRONJ development.

METHODS

A randomized, open-label, phase II, single-center clinical trial involving 117 patients at risk of MRONJ was conducted. The study protocol tested injections of an oxygen-ozone mixture in the post-extraction site. Participants were randomly assigned to two groups: oxygen-ozone therapy, and standard tooth extraction protocol. Post-extraction wound healing was assessed using the Inflammatory Proliferative Remodeling (IPR) Wound Healing Scale.

RESULTS

The oxygen-ozone therapy group exhibited a significant improvement in wound healing post-extraction during the inflammatory and proliferative phases, as indicated by the IPR scale scores at 3-5 days (p = 0.006) and 14 days (p < 0.001) respectively.

CONCLUSION

Oxygen-ozone therapy shows promise in improving post-extraction healing in patients at risk of MRONJ. Future studies with larger sample sizes and multicenter collaborations are recommended to confirm the validity of these findings and explore the long-term efficacy of ozone therapy.

Osteopenia: a key target for fracture prevention

Osteopenia was originally a qualitative term denoting bone that appeared to be less dense on radiographs. Since 1994, it has also had the quantitative meaning of a bone mineral density (BMD) T-score between -1·0 and -2·5. More than 60% of White women older than 64 years are osteopenic. Although fracture risk is often lower in osteopenic women than in those with osteoporosis, their greater number means that most fractures occur in osteopenic individuals. Fracture risk varies widely in the osteopenic range, depending on factors including BMD, age, fracture history, and nationality and ethnicity. Therefore, the diagnosis of osteopenia is not an indication for either intervention or reassurance, but BMD is a risk factor that should be incorporated into a quantitative fracture risk calculation. Evidence from trials shows that oral and intravenous bisphosphonates cost-effectively reduce fractures in older osteopenic women. Major osteoporotic fracture risks of 10-15% could be acceptable indications for treatment with generic bisphosphonates in patients older than 65 years motivated to receive treatment. This Review assesses the evidence relating to the management of older adults with osteopenic bone densities.

What Affects Healing Rates in Patients Treated for Medication-Related Osteonecrosis of the Jaw? The Role of Operative Therapy and Other Clinical Factors

BACKGROUND

In the therapy of medication-related osteonecrosis of the jaw (MRONJ), the healing rate, effectiveness of operative therapy, and factors associated with healing remain unclear.

PURPOSE

This study aimed to estimate MRONJ therapy healing rates and identify associated prognostic factors.

STUDY DESIGN, SETTING, SAMPLE

A 25-center prospective cohort study was conducted on 291 patients with MRONJ treated with a common therapeutic protocol during 2013-2016. Patients unable to continue examinations or treatment were excluded.

PREDICTOR VARIABLE

The primary predictor variable was MRONJ therapy grouped into two categories: operative and nonoperative. Secondarily, the prognostic factors categorized as demographic, medical, clinical, and perioperative were evaluated.

MAIN OUTCOME VARIABLES

The primary outcome variable was treatment duration, defined as the time (in months) between the initiation of therapy and when the site was healed or the date of the final visit or loss to follow-up.

COVARIATES

Not applicable.

ANALYSES

Descriptive statistics and 3-year cumulative healing rates were calculated. The association between clinical factors and time to healing was analyzed using bivariate and multivariate analyses and propensity score analysis. P < .05 was considered significant.

RESULTS

We analyzed data from 291 subjects with 76 (26.1%) and 215 (73.9%) subjects in the operative and nonoperative therapy groups, respectively. The healing rates for operative and nonoperative therapies were 95.8 and 70.7%, respectively (hazard ratio [HR] = 1.6, 95% confidence interval [CI] = 1.1-2.2, P value [P] < .01). The healing rates in patients for whom anti-resorptive agent (ARA) treatment was discontinued and continued were 87.2 and 37.4%, respectively (HR = 1.8, 95% CI = 1.1-3.0, P = .02). In a multiple regression analysis using ARA indication, the therapy method showed a significant association in the MRONJ malignancy group (HR = 2.75, 95% CI = 1.46-5.17, P < .01).

CONCLUSION AND RELEVANCE

Operative therapy and ARA discontinuation were associated with better healing rates in MRONJ therapy. However, the choice of therapy for MRONJ should be based on a comprehensive consideration of the patient's condition. ARA discontinuation should be considered an adjunctive measure because of the possibility of adverse events such as fragility fractures and skeletal related events.

The Efficacy and Safety of Bisphosphonate Therapy for Osteopenia/Osteoporosis in Patients With Chronic Kidney Disease: A Systematic Review and Individual Patient-Level Meta-Analysis of Placebo-Controlled Randomized Trials

Background

The efficacy and safety of bisphosphonate therapy for the treatment of osteoporosis and osteopenia in the setting of chronic kidney disease (CKD) is unclear.

Objective

To determine the effect of bisphosphonate therapy on fractures, bone mineral density (BMD), and adverse events in adults across the spectrum of CKD and dialysis.

Design

Systematic review and individual patient-level meta-analysis.

Setting

Searches of Ageline, CINAHL, the Cochrane Library, EMBASE, and Medline from inception to August 25, 2016, supplemented with manual screening and clinicalstudydatarequest.com. Authors were contacted for individual patient-level data.

Patients

Randomized, placebo-controlled trials with 100 or more participants that evaluated the treatment of primary osteoporosis/osteopenia in adult men and women with bisphosphonate therapy.

Measurements

Study characteristics, quality, and data were assessed independently by 2 reviewers. Outcome measures were fractures, BMD, and adverse events including decline in estimated glomerular filtration rate (eGFR) and hypocalcemia (calcium <2.00 mmol/L).

Methods

Single-stage individual patient-level meta-analysis.

Results

Of 39 eligible studies, individual patient-level data was available for 7 studies, all of which were studies of ibandronate. Of 7428 participants (5010 ibandronate, 2418 placebo), 100% were female, 98.6% were white, the mean body mass index was 25.7 kg/m2 (SD 3.9), 18.9% were smokers and there were 740 fracture events. The mean eGFR was 69.1 mL/min/1.73 m2 (SD 15.9) including 14.5%, 54.9%, 27.5%, 3.0%, and 0.2% stages G1, G2, G3A, G3B, and G4 CKD. Ibandronate increased hip and lumbar spine BMD and decreased the risk of fracture in the overall population (hazard ratio (HR) 0.871, 95% confidence interval (CI) 0.746, 1.018) but in patients with stage G3B CKD, it increased the risk of fracture (HR 3.862, 95% CI 1.156, 12.903). Ibandronate did not impact eGFR over 12 months but increased the risk of hypocalcemia (HR 1.324, 95% CI 1.056, 1.660) with no evidence of any effect modification by CKD stage (all tests of interaction p > 0.05).

Limitations

Clinically significant heterogeneity among studies, lack of long-term follow-up and bone biopsy results, limited representation of stage G4 and G5 CKD patients.

Conclusions

Chronic kidney disease potentially modifies the efficacy but not the safety of bisphosphonate therapy in osteopenia and osteoporosis.

Registration

PROSPERO CRD42020145613.

Medications Affecting Treatment Outcomes in Dentistry: Part 2

Today, it is common for medically complex patients who are receiving multiple medications, to seek routine and emergent dental care. It is essential for the practitioner to recognize and comprehend the impact of such medications on the patient's ability to tolerate the planned dental treatment and on dental treatment outcomes. An active appraisal of current literature is essential to stay abreast of emerging findings and understand their treatment implications. This article outlines the process of such active critical appraisal, illustrating key paradigms of the models that describe the impact of medications on treatment outcomes.

Current therapeutic approach of chronic kidney disease-mineral and bone disorder

Chronic kidney disease (CKD) has emerged as one of the leading noncommunicable diseases affecting >10% of the population worldwide. Bone and mineral disorders are a common complication among patients with CKD resulting in a poor life quality, high fracture risk, increased morbidity and cardiovascular mortality. According to Kidney Disease: Improving Global Outcomes, renal osteodystrophy refers to changes in bone morphology found in bone biopsy, whereas CKD-mineral and bone disorder (CKD-MBD) defines a complex of disturbances including biochemical and hormonal alterations, disorders of bone and mineral metabolism and extraskeletal calcification. As a result, the management of CKD-MBD should focus on the aforementioned parameters, including the treatment of hyperphosphatemia, hypocalcemia, abnormal PTH and vitamin D levels. Regarding the bone fragility fractures, osteoporosis and renal osteodystrophy, which constitute the bone component of CKD-MBD, anti-osteoporotic agents constitute the mainstay of treatment. However, a thorough elucidation of the CKD-MBD pathogenesis is crucial for the ideal personalized treatment approach. In this paper, we review the pathology and management of CKD-MBD based on the current literature with special attention to recent advances.

Medications Affecting Outcomes and Prognosis of Dental Treatment: Part 1

This article gives valuable insight into the effect of selected groups of medications on dental treatment outcome and prognosis. The review emphasizes the importance of thorough medical history, which may have an impact on the prognosis of dental treatment. We discuss drugs acting on the central nervous system, gastrointestinal tract, respiratory tract, endocrine system, and bone metabolism among others. Other pertinent drugs are discussed elsewhere in this special issue.

Synergistic effect between denosumab and immune checkpoint inhibitors (ICI)? A retrospective study of 268 patients with ICI and bone metastases

Background

Bone metastasis is a significant concern in advanced solid tumors, contributing to diminished patient survival and quality of life due to skeletal-related events (SREs). Denosumab (DMAB), a monoclonal antibody targeting the receptor activator of nuclear factor kappa-B ligand (RANKL), is used to prevent SREs in such cases. The RANK/RANKL axis, crucial in immunological processes, has garnered attention, especially with the expanding use of immune checkpoint inhibitors (ICI) in modern oncology.

Objective

Our study aims to explore the potential synergistic antitumor effects of combining immunotherapy with denosumab, as suggested by anecdotal evidence, small cohort studies, and preclinical research.

Methods

We conducted a retrospective analysis using the IMMUCARE database, encompassing patients receiving ICI treatment since 2014 and diagnosed with bone metastases. We examined overall survival (OS), progression-free survival (PFS) and switch of treatment line based on denosumab usage. Patients were stratified into groups: without denosumab, ICI followed by denosumab, and denosumab followed by ICI. Survival curves and multivariate Cox regression analyses were performed.

Results

Among the 268 patients with bone metastases, 154 received treatment with ICI alone, while 114 received ICI in combination with denosumab at some point during their oncological history. No significant differences were observed in overall survival (OS) or progression-free survival (PFS) between patients receiving ICI monotherapy and those receiving ICI with denosumab (p = 0.29 and p = 0.79, respectively). However, upon analyzing patients who received denosumab following ICI initiation (17 patients), a notable difference emerged. The group receiving ICI followed by denosumab exhibited a significant advantage compared to those without denosumab (154 patients) or those receiving denosumab before ICI initiation (72 patients) (p = 0.022).

Conclusion

This retrospective investigation supports the notion of potential benefits associated with sequential administration of ICI and denosumab, although statistical significance was not achieved. Future studies, including prospective trials or updated retrospective analyses, focusing on cancers treated with first-line immunotherapy, could provide further insights into this therapeutic approach.

Development and validation of a clinical prediction model for osteonecrosis of the jaw in patients receiving zoledronic acid using FAERS and canadian databases

Background

Osteonecrosis of the jaw (ONJ) stands as a severe complication linked to the use of bisphosphonates, particularly zoledronic acid, which is widely prescribed for managing conditions like osteoporosis and bone metastasis. This study is geared towards the development and validation of a clinical prediction model for ONJ in patients undergoing zoledronic acid treatment.

Methods

We harnessed data from the FDA Adverse Event Reporting System (FAERS) as our training dataset, while the Canada Vigilance Adverse Reaction (CVAR) database served as the testing dataset. The study encompassed patients treated with zoledronic acid and subsequently diagnosed with ONJ. We analysed a range of predictive factors, including breast cancer, bone metastasis, osteoporosis, vitamin D and calcium levels, comorbidities, the number of concomitant medications, dosage, age, weight, and gender. Logistic regression and nomogram analysis were the chosen methodologies for constructing the predictive model. To evaluate the model's performance, we utilized receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

Results

The study encompassed a total of 2,126 patients in the training cohort, 911 patients in the internal test cohort from the FAERS database, and 121 patients in the external test cohort from the CVAR database. Notable predictors for ONJ included bone metastasis (OR: 1.65, 95% CI: 1.22-2.24), osteoporosis (OR: 0.33, 95% CI: 0.21-0.52), the number of concomitant medications (OR: 1.07, 95% CI: 1.05-1.09), and the dosage of zoledronic acid (OR: 1.24, 95% CI: 1.10-1.39). The nomogram exhibited robust discriminatory power, evidenced by an area under the curve (AUC) of 0.77 in the training cohort, 0.76 in the internal test cohort, and 0.90 in the external test cohort. Calibration plots demonstrated a strong alignment between observed and predicted probabilities. Furthermore, DCA highlighted the prediction model's significant net benefit across various threshold probabilities.

Conclusion

By leveraging data from both the FAERS and Canadian databases, this study has successfully developed and validated a clinical prediction model for ONJ in patients receiving zoledronic acid. This model stands as a valuable tool for clinicians, enabling them to pinpoint high-risk patients and make evidence-based treatment decisions to minimize the risk of ONJ.

Approach to Bone Health in the Patient With Breast Cancer

Treatment for breast cancer, including endocrine therapies, can contribute to bone loss and increase the risk of osteoporosis and fractures. Management of bone health in patients with cancer is often coordinated between oncologists, endocrinologists, and primary care physicians. In this article, we discuss the approach to screening for fracture risk among patients initiating treatments for breast cancer and recommendations for lifestyle modifications to optimize bone health. We will review 3 indications for pharmacologic bone-targeted therapies: prevention of cancer treatment-induced bone loss, adjuvant therapy to reduce recurrence, and management of bone metastases.

Hydroxychloroquine and a low antiresorptive activity bisphosphonate conjugate prevent and reverse ovariectomy-induced bone loss in mice through dual antiresorptive and anabolic effects

Osteoporosis remains incurable. The most widely used antiresorptive agents, bisphosphonates (BPs), also inhibit bone formation, while the anabolic agent, teriparatide, does not inhibit bone resorption, and thus they have limited efficacy in preventing osteoporotic fractures and cause some side effects. Thus, there is an unmet need to develop dual antiresorptive and anabolic agents to prevent and treat osteoporosis. Hydroxychloroquine (HCQ), which is used to treat rheumatoid arthritis, prevents the lysosomal degradation of TNF receptor-associated factor 3 (TRAF3), an NF-κB adaptor protein that limits bone resorption and maintains bone formation. We attempted to covalently link HCQ to a hydroxyalklyl BP (HABP) with anticipated low antiresorptive activity, to target delivery of HCQ to bone to test if this targeting increases its efficacy to prevent TRAF3 degradation in the bone microenvironment and thus reduce bone resorption and increase bone formation, while reducing its systemic side effects. Unexpectedly, HABP-HCQ was found to exist as a salt in aqueous solution, composed of a protonated HCQ cation and a deprotonated HABP anion. Nevertheless, it inhibited osteoclastogenesis, stimulated osteoblast differentiation, and increased TRAF3 protein levels in vitro. HABP-HCQ significantly inhibited both osteoclast formation and bone marrow fibrosis in mice given multiple daily PTH injections. In contrast, HCQ inhibited marrow fibrosis, but not osteoclast formation, while the HABP alone inhibited osteoclast formation, but not fibrosis, in the mice. HABP-HCQ, but not HCQ, prevented trabecular bone loss following ovariectomy in mice and, importantly, increased bone volume in ovariectomized mice with established bone loss because HABP-HCQ increased bone formation and decreased bone resorption parameters simultaneously. In contrast, HCQ increased bone formation, but did not decrease bone resorption parameters, while HABP also restored the bone lost in ovariectomized mice, but it inhibited parameters of both bone resorption and formation. Our findings suggest that the combination of HABP and HCQ could have dual antiresorptive and anabolic effects to prevent and treat osteoporosis.

Influence of the use of bisphosphonates on the development of postextraction sequelae: Scoping review with mapping evidence of in vivo studies

OBJECTIVE

To map the current scientific landscape regarding the association/causality of medication-related osteonecrosis of the jaw (MRONJ) after tooth extraction under bisphosphonate (BF) therapy to identify knowledge gaps and guide future research.

DATA

This review used the PCC strategy (P = Patient; C = Concept; C = Context).

SOURCES

The MEDLINE/PubMed, Scopus, Web of Science/Clarivate Analytics, and gray literature databases were used.

STUDY SELECTION

Searches were conducted by two independent reviewers until April 2024. Studies involving prior BF use and tooth extraction in humans or animals were included. Among the 176 studies, 73 (41.4 %) were in animals, and 103 (58.5 %) were in humans. Brazil led in animal studies (n = 14; 19.1 %), while Italy led in human studies (n = 14; 13.6 %). Zoledronic acid was the most cited BF (79.4 % in animals; 34.9 % in humans), with intravenous administration being most frequent (38.3 % in animals; 35.9 % in humans). The mandible was the main extraction site (n = 36 in animals; n = 41 in humans). In 91.7 % of the animal studies, sequelae compatible with osteonecrosis signs and symptoms were observed, with bone necrosis being most common (n = 39; 53.4 %). In humans, 93.2 % of studies presented 239 sequelae, with bone necrosis (n = 53; 22.1 %) being the most cited. The main location of sequelae was the mandible (n = 36 in animals; n = 41 in humans).

CONCLUSIONS

Animal studies highlighted bone exposure, notably using murine models, with a significant Brazilian contribution. In human studies, bone necrosis was the main sequela of MRONJ, which has been reported by researchers in the Italy.

CLINICAL SIGNIFICANCE

These findings underscore the importance of careful consideration and monitoring of patients who have a history of bisphosphonate use and who are undergoing tooth extraction, highlighting the potential risk of MRONJ.

The Effectiveness of Hyperbaric Oxygen Therapy on Older Patients With Medication-Related Osteonecrosis of the Jaws: A Case Series

Medication-related osteonecrosis of the jaws (MRONJ) has emerged as one of the major adverse effects of antiresorptive agents in the treatment of patients with cancer and osteoporosis. MRONJ presents as a chronic inflammation of the maxillary and/or mandibular bones accompanied by necrotic bone exposure and intra-/extraoral fistula. Given the increasing number of patients with MRONJ, surgical treatment is highlighted to be significantly beneficial for those patients. However, extensive surgical treatment generally induces physiological and psychological burden on patients with MRONJ. Specifically, older patients with advanced MRONJ require further concerns about their systemic conditions. Thus, oral surgeons are obliged to consider their conditions when determining the indications for extensive surgical treatment. Recently, our department has established a novel therapeutic strategy based on hyperbaric oxygen (HBO) therapy for patients with advanced MRONJ. In this study, we report cases of three older patients with MRONJ who received the combination of conventional treatment and HBO therapy, which resulted in successful management and the avoidance of extensive surgical treatment.

Surgical and conservative treatment outcomes of medication-related osteonecrosis of the jaw located at tori: a retrospective study

PURPOSE

Tori and exostoses are considered risk factors for the development of medication-related osteonecrosis of the jaw (MRONJ). The aims of this study were to present the prevalence of MRONJ located at tori in the Copenhagen ONJ Cohort, evaluate the surgical treatment of MRONJ located at tori and explore trauma to tori as an additional risk factor in patients on antiresorptive medication.

METHODS

Data from a consecutive series of 506 patients with MRONJ (Copenhagen ONJ Cohort) were reviewed for the presence of tori and MRONJ located at tori. Demographic and medical data were analyzed, and healing outcomes and pain after the prophylactic removal of tori, surgical treatment of MRONJ located at tori, and conservative treatment of MRONJ located at tori were evaluated and compared using Fisher's exact test.

RESULTS

MRONJ located at tori was frequent and could be identified in 53% of the patients with tori, which accounts for a prevalence of 5.1% in the entire cohort. Of the 28 surgically treated patients, 27 (96.4%) healed uneventfully with no exposed bone after their first or second revision surgery. Fourteen (41.2%) patients with tori underwent therapeutic removal, eight (23.5%) underwent prophylactic removal, and six (17.6%) underwent both therapeutic and prophylactic removals. Two (33.3%) of the six conservatively treated patients healed spontaneously. Both treatment types resulted in a significant decrease in pain.

CONCLUSION

Prophylactic and therapeutic surgical removal of tori are reliable treatments and should be considered if a patient's general health allows surgery.

TRIAL REGISTRATION

The study was approved by the Regional Scientific Ethical Committee (H-6-2013-010) on November 20, 2013, and was retrospectively registered.

Medication-related osteonecrosis of the jaw: Evaluation of a therapeutic strategy in oral surgery

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse illness linked to antiresorptive therapies (ART), for which there is no therapeutic gold standard. Many factors can influence MRONJ evolution such as cancer type, treatment, comorbidities, and accumulated dose of ART. The aim of this study was to determine the influencing factors of MRONJ treatments success.

METHODS

This retrospective study focused on patients treated for MRONJ in a French tertiary centre. Non-operative therapy was always applied, ART were suspended if appropriate, and surgery (MRONJ removal and musculo-mucosal flap reconstruction) was performed in the absence of contraindication. The evaluation criteria were bone and mucosal healing 3 months after surgery.

RESULTS

81 MRONJ were included; medical treatment alone was administered to 26 % while the remaining 74 % received additional surgery. Therapeutic success reached 86.7 % (52/60) for surgery compared to 42.9 % (9/21) for medical treatment alone (p < 0.001). Age (OR=1.08, p = 0.014) and the absence of infection (OR=5.32, p = 0.042) were in favour of success, while medical treatment alone (OR=0.03, p < 0.001) was highly unfavourable.

CONCLUSION

MRONJ healing is influenced by age, non-infectious stages, and surgery. Additional surgery in MRONJ treatment should be advised if the health of the patient permits.

Cost-Effectiveness of Artificial Intelligence-Based Opportunistic Compression Fracture Screening of Existing Radiographs

PURPOSE

Osteoporotic vertebral compression fractures (OVCFs) are a highly prevalent source of morbidity and mortality, and preventive treatment has been demonstrated to be both effective and cost effective. To take advantage of the information available on existing chest and abdominal radiographs, the authors' study group has developed software to access these radiographs for OVCFs with high sensitivity and specificity using an established artificial intelligence deep learning algorithm. The aim of this analysis was to assess the potential cost-effectiveness of implementing this software.

METHODS

A deterministic expected-value cost-utility model was created, combining a tree model and a Markov model, to compare the strategies of opportunistic screening for OVCFs against usual care. Total costs and total quality-adjusted life-years were calculated for each strategy. Screening and treatment costs were considered from a limited societal perspective, at 2022 prices.

RESULTS

In the base case, assuming a cost of software implantation of $10 per patient screened, the screening strategy dominated the nonscreening strategy: it resulted in lower cost and increased quality-adjusted life-years. The lower cost was due primarily to the decreased costs associated with fracture treatment and decreased probability of requiring long-term care in patients who received preventive treatment. The screening strategy was dominant up to a cost of $46 per patient screened.

CONCLUSIONS

Artificial intelligence-based opportunistic screening for OVCFs on existing radiographs can be cost effective from a societal perspective.

Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ)

OBJECTIVE

This paper aims to describe the 2023 update position paper on MRONJ developed by the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Maxillofacial Surgery (SICMF).

METHODS

This is the second update following the 2013 and 2020 Italian position papers by the Expert panel, which is a representation of the two scientific societies (SIPMO and SICMF). The paper is based on an extensive analysis of the available literature from January 2003 to February 2020, and the subsequent review of literature conducted between March 2020 and December 2022 to include all new relevant published papers to confirm or modify the previous set of recommendations.

RESULTS

This position paper highlights the main issues of MRONJ on risk estimates, disease definition, diagnostic pathway, individual risk assessment, and the fundamental role of imaging in the diagnosis, classification, and management of MRONJ.

CONCLUSION

The Expert Panel confirmed the MRONJ definition, the diagnostic work-up, the clinical-radiological staging system and the prophylactic drug holiday, as recognized by SIPMO-SICMF; while, it presented novel indications regarding the categories at risk of MRONJ, the prevention strategies, and the treatment strategies associated with the therapeutic drug holiday.

Analysis of bone single-photon emission CT/CT and diffusion-weighted MR imaging in medication-related osteonecrosis of the jaw: focusing on the correlation between standardized uptake values and apparent diffusion coefficient values

The purpose of this study is to investigate bone SPECT/CT and diffusion-weighted MR imaging (DWI) in medication-related osteonecrosis of the jaw (MRONJ), focusing on the correlation between standardized uptake values (SUVs) and apparent diffusion coefficient (ADC) values. Twenty-nine patients with MRONJ who underwent SPECT/CT and DWI were included in this study. SUVs (maximum and mean) with SPECT/CT, and ADC values (maximum, mean and minimum) with DWI were analyzed on characteristics in MRONJ, such as stage, location, medication and underlying disease, by Mann-Whitney U test. Furthermore, the correlation between SUVs and ADC values for characteristics in MRONJ were assessed by Spearman's rank correlation test for nonparametric data. A p-value lower than 0.05 was considered as statistically significant. SUVs and ADC values have no significant differences for all characteristics in MRONJ. Negative correlations were found in all cases and in stage 2 cases, and no correlations were found in stage 3 cases. In addition, negative correlations were found in maxillary cases, mandibular cases, non-bisphosphonate cases, osteoporosis cases, and malignant tumor cases. In conclusion, this study found multiple correlations between SUVs and ADC values in MRONJ, especially in stage 2. Suggesting that ADC values and SUVs may change with disease progression and the possibility of predicting MRONJ progression by SUVs and ADC values.

A retrospective case series on bisphosphonate related osteonecrosis of the jaw in 20 cats

Introduction

This retrospective study highlights the salient aspects of a series of feline patients affected with bisphosphonate related osteonecrosis of the jaw. Though more commonly published in human literature, this presentation is rare in cats. The authors hope that this study will assist in making this a more globally known entity with subsequent improved prognosis.

Methods

Data was retrospectively obtained from the medical records between 2015 and 2021 of 20 cats with Medication Related Osteonecrosis of the Jaw. Data included patient information, clinical history, presenting complaint, systemic diseases, details referable to hypercalcemia and treatment thereof, bisphosphonate specifics (dose and duration), clinical presentation of the lesion, diagnostic testing including radiographic and histopathologic descriptions, treatment, and outcome.

Results

Pertinent results include that all 20 cats who developed Medication Related Osteonecrosis of the Jaw had been treated for idiopathic hypercalcemia with the bisphosphonate medication alendronate. Eighty-five percent of the cases had prior dental extractions at the site of MRONJ lesion. Ninety-five percent of the affected cats required a surgical procedure to control the disease. Thirty-five percent of cases required at least one revision surgery after the initial procedure was performed. Diagnosis of MRONJ was made by a correlation of diagnostic findings and patient history. No single diagnostic, or combination was pathognomonic for lesion diagnosis. As well, there were no statistically significant associations between patient variables assessed and the overall patient outcome.

Discussion

The case series reveals that cats with feline idiopathic hypercalcemia treated with alendronate may be at a risk for development of MRONJ, a serious oral condition with significant morbidity. Prior dental extraction sites in patients concurrently treated with bisphosphonate medications were often associated with MRONJ lesions. Therefore, any needed dental surgery should be performed prior to the use of bisphosphonates where possible. The authors have also included a relevant comparative literature review.

How we manage medication-related osteonecrosis of the jaw

Bone-modifying agents (BMAs) are integral to managing patients with advanced cancer. They improve quality of survival by reducing skeletal-related events, treating hypercalcaemia and chemotherapy-induced bone loss (Coleman in Clin Cancer Res 12: 6243s-6249s, 2006), (Coleman in Ann Oncol 31: 1650-1663, 2020). Two decades ago, medication-related osteonecrosis of the jaw (MRONJ) was first reported following BMA therapy (Marx in J Oral Maxillofac Surg 61: 1115-1117, 2003). The risk of MRONJ extends over a decade following BMA treatment with bisphosphonates, complicating dental care such as extractions. In addition, MRONJ has been reported following additional therapies such as antiangiogenic agents, cytotoxic agents, immunotherapy, and targeted agents. The use of BMAs in the curative and adjuvant cancer setting is increasing, consequently the implication of MRONJ is growing. Over the past 20 years, the literature has consolidated major risk factors for MRONJ, the pathophysiology and management strategies for MRONJ. Our review aims to document the development of MRONJ preventative and management strategies in cancer patients receiving a BMA. The authors advocate the incorporation of dental oncology strategies into contemporary cancer care, to optimise long-term quality of survival after cancer treatment.

Microvascular reconstruction of medication related osteonecrosis of the head and neck

BACKGROUND

Medication related osteonecrosis of the jaw (MRONJ) requiring free flap (FF) reconstruction is uncommon with limited reported findings.

METHODS

Multicenter, retrospective case series of 49 consecutive adult patients presenting with advanced MRONJ requiring FF reconstruction from 2010 to 2022. Perioperative complications and outcomes were analyzed.

RESULTS

Eighty-two percent (n = 40) of cases were of the mandible and 18% (n = 9) were of the maxilla. The mean follow-up was 15 months (±19.6). The majority of FF survived (96%, n = 47). FF reconstructions of the maxilla were more likely to require postoperative debridement (56%, 95% CI [27, 81%] vs. 15%, 95% CI [7, 25%], p = 0.008) or develop intraoral bone exposure (56%, 95% CI [27, 81%] vs. 18%, 95% CI [9, 27%], p = 0.02). Most patients (71%, n = 35) received preoperative antibiotics which was associated with a higher rate of FF survival (100% vs. 86%, 95% CI [60, 96%], p = 0.02) and fewer complications.

CONCLUSIONS

Patients undergoing FF reconstruction for MRONJ do well with high rates of FF success. MRONJ of the maxilla have a higher rate of some complications. Preoperative antibiotics correlated with higher FF survival and fewer postoperative complications.

What Is the Appropriate Antibiotic Administration During Tooth Extractions in Patients Receiving High-Dose Denosumab?

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) occasionally occurs following tooth extractions in cancer patients receiving denosumab (Dmab). However, there are currently no established guidelines for perioperative antibiotic administration during tooth extraction in these patients. The primary objective was to develop guidelines for the dose and frequency of antibiotics during tooth extraction by investigating the correlation between the current status of antibiotic administration and the development of MRONJ.

METHODS

This study included 68 cancer patients receiving high-dose Dmab who had tooth extractions between 2012 and 2022 at 10 hospitals. The relationship between the way of perioperative antibiotic administration and the development of MRONJ was analyzed. A P-value < .05 was considered significant.

RESULTS

There was considerable variability across hospitals and surgeons regarding the type, dosage, and duration of antibiotic administration. Amoxicillin (AMPC) was the most commonly used antibiotic. Focusing exclusively on teeth extracted under AMPC administration, MRONJ developed in 21 out of 123 teeth (17.0%). No significant relationship was found between the development of MRONJ and the dosage or duration of perioperative AMPC administration.

CONCLUSION

Perioperative antibiotic administration alone may not be sufficient to prevent MRONJ. Therefore, a single preoperative dose is likely adequate for effective and appropriate AMPC administration.　.

Role of Photodynamic Therapy in Osteonecrosis and Osteoradionecrosis of the Jaws: A Systematic Review

Aim

Photodynamic therapy (PDT) is a minimally invasive treatment modality that has been used clinically for early stage and inoperable cancers. Successful use of this atraumatic therapy in osteoradionecrosis (ORN) and osteonecrosis of the jaws (ONJ) has been documented in the literature. The aim of this review was to systematically evaluate the role of photodynamic therapy in ORN and ONJ.

Methods

Two independent reviewers conducted an elaborate search in PubMed, Google Scholar and Cochrane's CENTRAL database for studies published on PDT as stand-alone or adjuvant therapy in ORN/ONJ until June 2022. The present study was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Demographic data, type and stage of necrosis of the jaws, site, PDT protocol, time to heal and follow-up were evaluated. Eighteen articles were included totally based on the inclusion and exclusion criteria for final analysis.

Results

A total of 94 patients were included in the present review out of which 36 were males and 58 were females. Five studies reported the use of PDT as an adjuvant therapy in ORN. Thirteen studies reported successful outcomes with PDT in ONJ. Complete epithelialization was achieved with PDT ± other adjuvants in 86/94 (91.48%) patients. The time taken for regression of the lesion ranged between 4 days and 12 months with PDT in the present study.

Conclusion

The reviewed studies demonstrate the effectiveness of PDT, as an adjuvant therapy, in managing various stages of ORN and ONJ.

A Systematic Review of Laser Photobiomodulation Dosimetry and Treatment Protocols in the Management of Medications-Related Osteonecrosis of the Jaws: A Rationalised Consensus for Future Randomised Controlled Clinical Trials

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating adverse effect of bisphosphates, antiresorptive therapy or antiangiogenic agents that can potentially increase oxidative stress, leading to progressive osteonecrosis of the jaws. Despite the large number of published systematic reviews, there is a lack of potential MRONJ treatment protocols utilising photobiomodulation (PBM) as a single or adjunct therapy for preventive or therapeutic oncology or non-oncology cohort. Hence, this systematic review aimed to evaluate PBM laser efficacy and its dosimetry as a monotherapy or combined with the standard treatments for preventive or therapeutic approach in MRONJ management. The objectives of the review were as follows: (1) to establish PBM dosimetry and treatment protocols for preventive, therapeutic or combined approaches in MRONJ management; (2) to highlight and bridge the literature gaps in MRONJ diagnostics and management; and (3) to suggest rationalised consensus recommendations for future randomised controlled trials (RCTs) through the available evidence-based literature. This review was conducted according to the PRISMA guidelines, and the protocol was registered at PROSPERO under the ID CRD42021238175. A multi-database search was performed to identify articles of clinical studies published from their earliest records until 15 December 2023. The data were extracted from the relevant papers and analysed according to the outcomes selected in this review. In total, 12 out of 126 studies met the eligibility criteria. The striking inconsistent conclusions made by the various authors of the included studies were due to the heterogeneity in the methodology, diagnostic criteria and assessment tools, as well as in the reported outcomes, made it impossible to conduct a meta-analysis. PBM as a single or adjunct treatment modality is effective for MRONJ preventive or therapeutic management, but it was inconclusive to establish a standardised and replicable protocol due to the high risk of bias in a majority of the studies, but it was possible to extrapolate the PBM dosimetry of two studies that were close to the WALT recommended parameters. In conclusion, the authors established suggested rationalised consensus recommendations for future well-designed robust RCTs, utilising PBM as a monotherapy or an adjunct in preventive or therapeutic approach of MRONJ in an oncology and non-oncology cohort. This would pave the path for standardised PBM dosimetry and treatment protocols in MRONJ management.

Osteonecrosis of the Jaws Associated with Herpes Zoster Infection: A Systematic Review and a Rare Case Report

The investigation's goal was to obtain further knowledge about the connection between Herpes Zoster infection and dentistry therapy for the osteonecrosis of the jaws, combining the review with a case report relevant to the purpose. It is important to study this association because it is a possible additional factor to be considered in the causes of the osteonecrosis of the jaws. We limited our search to English-language papers published between 1 January 2004 and 7 June 2024 in PubMed, Scopus, and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "Herpes Zoster AND osteonecros*" were used. Results: This study analyzed 148 papers from Web of Science, PubMed, and Scopus, resulting in 95 articles after removing duplicates. Of these, 49 were removed because they were off topic, and 46 were confirmed. This study includes a qualitative analysis of the final 12 articles, removing 34 articles that were off topic. The literature highlights severe oral complications from Herpes Zoster reactivation, emphasizing the need for early diagnosis, comprehensive management, and multidisciplinary care. Treatment strategies include antiviral therapy, pain management, surgical debridement, and antibiotics. Immunocompromised individuals require vigilant monitoring and balanced immunosuppressive therapy. Further research is needed to enhance therapeutic approaches.

Comparing the effects of low-level laser therapy and gaseous ozone as a preventive measure on medication-related osteonecrosis of the jaws following tooth extraction: a rat model

OBJECTIVES

Use of numerous medications such as tyrosine kinase inhibitors (sunitinib), monoclonal antibodies (bevacizumab), fusion proteins (aflibercept), mTOR inhibitors (everolimus), radiopharmaceuticals (radium 223), selective estrogen receptor modulators (raloxifene), and immunosuppressants (methotrexate and corticosteroids) has been reported to be a risk factor for development of medication-related osteonecrosis of the jaws till date. This study aimed to evaluate the preventive effect of low-level laser therapy (LLLT) and gaseous ozone on the onset of MRONJ following tooth extraction.

MATERIALS AND METHODS

A total of 40 male Wistar rats were randomly allocated into 4 groups of 10 rats each. The groups laser (L), ozone (O), and control (C) received weekly intraperitoneal injections of zoledronic acid (0.06 mg/kg), while group sham (S) received saline solution for 4 weeks. After the 4th injection, all subjects underwent mandibular first molar extraction and adjunctive laser or ozone was applied according to the groups. All the rats were sacrificed at 4 postoperative weeks for comparative histomorphometric evaluation of bone healing in extraction sites.

RESULTS

Laser and ozone groups demonstrated significantly higher bone formation compared to control group (p < 0.05), while no significant difference was found between laser and ozone groups (p = 1.00). Furthermore, the greatest bone formation was observed with the sham group (p < 0.05).

CONCLUSIONS

Findings of the current study support that adjunctive LLLT and ozone therapy following tooth extraction may help prevent MRONJ and improve bone healing in subjects under zoledronic acid therapy.

CLINICAL RELEVANCE

Since the introduction in 2003, great effort has been devoted to developing a certain management protocol for MRONJ. Several publications have appeared in recent years documenting promising results of adjunctive LLLT and ozone application in treatment of MRONJ. However, experimental data are limited on this regard and the present study, for the first time, aimed to evaluate and compare the effects of LLLT and ozone in prevention of MRONJ.

Factors affecting the quality of life of patients with medication-related osteonecrosis of the jaw during treatment: A quality-of-life survey and causal analysis

This prospective cohort study aimed to investigate the impact of medication-related osteonecrosis of the jaw (MRONJ) on health-related quality of life (HRQOL) and oral health-related QOL (OHRQOL) and the association between the downstaging of MRONJ and OHRQOL. The HRQOL and OHRQOL of 44 patients with MRONJ were assessed using the SF-36v2 and the General Oral Health Assessment Index (GOHAI), respectively. Treatment was performed in accordance with the AAOMS position paper (2014). The SF-36v2 and GOHAI scores at the beginning of the survey were used to evaluate the impact of MRONJ on QOL. Potential confounders affecting the association between downstaging and QOL improvement were selected using directed acyclic graphs. Multiple regression analysis was performed to evaluate causal inferences. HRQOL scale scores declined below the national average. The three-component summary score (3CS), comprising the physical component summary (PCS), mental component summary (MCS), and role/social component summary (RCS), revealed that performance status and primary disease significantly affected the PCS and RCS (P = 0.005 and P < 0.001, respectively) and PCS and MCS (P = 0.024 and P = 0.003, respectively). The MRONJ stage did not influence the 3CS; however, OHRQOL declined in a stage-dependent manner (P = 0.005). Downstaging of MRONJ was independently associated with the improvement rate of the total GOHAI scores after adjusting for variables (P = 0.045). The HRQOL of patients with MRONJ declined; however, this may depend on the underlying disease status rather than the MRONJ stage. Improvement of the disease status can potentially predict an improvement in OHRQOL, regardless of the treatment modality.

Effectiveness and Satisfaction with Telemedicine in Geriatric Patients at High Risk of Fragility Fractures

Background: Telemedicine has increasingly widespread to improve the monitoring of patients with chronic diseases. Secondary prevention of fragility fractures is an urgent matter to be addressed by means of available technology, although supported by little evidence so far. We investigated the feasibility, efficacy, and satisfaction of managing older adults at high risk of fragility fractures during the COVID-19 lockdown. Methods: During the period January to July 2021, a prospective observational study for safety and adherence purposes was conducted among older adults (n = 407) with ongoing treatments for secondary prevention of fragility fractures. The study procedures comply with national and regional resolutions related to telemedicine service (TS), including equipment, staff behaviors, and patient reports. Results: A majority (86.48% [n = 352]) of the eligible patients joined the remote visits, mainly women (88.2%), 81.4 ± 8.8 years of age, 49.6% independent in 5 out of 6 BADL, despite high comorbidity (4.9 ± 1.5), and polypharmacy (4.9 ± 3.1). Almost all were on second-line antifracture treatments (95.58%) due to previous major (84.03%) and minor (42.5%) fragility fractures. About 58% reported good and very good reliability of the internet network, allowing easy access to the TS platform, and 54% declared the degree of satisfaction with TS as good and very good. About 75% of clinicians acknowledged the efficacy of TS and expressed willingness to recommend the use of TS to colleagues. Ultimately, 68% of specialists defined the time allocated for patients' remote visits as acceptable. Conclusion: TS may be an opportunity to improve the availability of appropriate health care services to satisfy patients' needs and optimize health care resource allocation.

Postoperative Recurrence of Medication-Related Osteonecrosis of the Jaw: A Retrospective Study of 150 Patients Undergoing Surgery

Introduction Surgery is the recommended treatment for medication-related osteonecrosis of the jaw (MRONJ). However, the disease may recur postoperatively. We reviewed imaging findings in patients undergoing three or more surgeries. Patients and methods One hundred fifty patients with MRONJ underwent surgery at our hospital. Here, we present the characteristics of 34 surgeries in nine patients (two men and seven women; mean age, 73.9 years) who underwent surgery at least three times. Results Three and six patients had maxillary and mandibular lesions, respectively. The primary disease was malignancy in eight patients, and denosumab was used in seven patients. All patients initially underwent either partial maxillectomy or marginal mandibulectomy, and segmental mandibulectomy was not performed. The number of surgeries ranged from three to six (average, 3.8). Healing was eventually achieved in seven cases, but not in two cases. Of the 27 unsuccessful surgeries, postoperative cone-beam computed tomography revealed no residual osteolysis, periosteal reaction, or osteosclerosis after seven surgeries and some residual lesions after 19 surgeries; imaging was not performed after one surgery. In contrast, among the seven successful surgeries, no residual osteolysis, periosteal reaction, or osteosclerosis was observed in all six cases in which postoperative computed tomography was performed. Conclusion Recurrence is more common in patients with residual areas of osteolysis, periosteal reactions, or mixed-type osteosclerosis, and including these areas in the resection is desirable.

The effectiveness of autologous platelet concentrates in prevention and treatment of medication-related osteonecrosis of the jaws: A systematic review

The systematic review aims to answer the PICOS question: "Are the autologous platelet concentrates (APCs) an effective strategy in prevention and/or treatment of patients at risk of/affected by medication-related osteonecrosis of the jaws (MRONJ)?". A literature search was conducted via PubMed, MEDLINE, EMBASE, and CINAHL (January 2006 - September 2023). 30 articles were included, evaluating preventive (n = 8*) and treatment strategies (n = 23*). The risk of bias and quality of studies were assessed utilising ROB-2, ROBIN-1 and GRADE criteria. Meta-analysis was undertaken for eligible studies. The application of APCs demonstrated a statistically significant effectiveness in prevention of MRONJ in 86.13% (p < 0.001) but failed to achieve the same level of certainty in treatment of established MRONJ in 83.4% (p = 0.08). High levels of bias were identified; thus, the results should be interpreted with caution. More high quality prospective randomised controlled trials are needed to further evaluate the effectiveness of APCs in management of MRONJ.

Maxillary Osteonecrosis Related with Herpes Zoster: A Case Report and Review of the Literature

Osteonecrosis of the jaw (ONJ) can occur through various mechanisms including radiation, medication, and viral infections such as herpes zoster. Although herpes zoster is a varicella-zoster virus infection that can affect the trigeminal nerve, it rarely causes oral complications. The author reports a rare case of herpes zoster-related ONJ, followed by a review of the relevant literature pertaining to herpes zoster-related oral complications, including ONJ. A 73-year-old woman presented with a scarred skin lesion on her left midface with an exposed alveolar bone of the left maxilla. Based on her medical records, she received a diagnosis and treatment for herpes zoster six months prior and experienced a few teeth loss in the left maxilla following a fall preceding the onset of herpes zoster. Sequestrectomy of the left maxilla was performed and ONJ was diagnosed. The operative site recovered favorably. Although unusual, several cases of localized extensive ONJ in herpes zoster-infected patients have been reported. This case illustrates the possibility of a rare occurrence of unilateral widespread osteonecrosis of the jaw (ONJ) even in the maxilla associated with herpes zoster. The exact mechanism has not been elucidated; nevertheless, surgeons should consider the possibility of oral and dental complications, including ONJ, related to a history of herpes zoster.

Gelatin-Zinc Carrier as a New Method of Targeted and Controlled Release of Risedronate

The essence of drug delivery is to use an appropriate carrier that delivers the active substance to the appropriate pathogenic site at a specific time. This study aims to develop a novel drug carrier characterized by the controlled and targeted release of risedronate (RSD). The search for new routes to deliver RSD is important because oral delivery has many disadvantages. The carrier proposed in this work is composed of gelatin, polyphosphates, and zinc. The zinc contained in the carrier is responsible for coordinating the drug. The resulting material releases RSD in a controlled manner. The rate of delivery of the substance to the body depends on the pH of the environment. This study investigated the delivery of RSD in a neutral environment, where the process exhibited a prolonged and consistent release rate. This process has also been studied in an acidic environment, which accelerates the release of the drug. Mixed-environment studies were also conducted. Initially, the drug was released in a neutral environment, and then the conditions rapidly changed to acidic. In this case, the carrier demonstrated high stability and controlled release, adapting the rate of drug release to the prevailing environmental conditions. The presented results indicate the great potential of the new gelatin-based carrier in the delivery of risedronate.