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

Mild antiresorptive activity of an anti-vascular endothelial growth factor A antibody and sunitinib in a rat model of bone resorption

Medication-Related-Osteonecrosis-of-the-Jaw (MRONJ) is an adverse event linked to antiresorptives such as bisphosphonates and denosumab. While MRONJ predominantly affects cancer patients treated with these agents, it has been less frequently reported in cancer patients receiving angiogenesis inhibitors (AgIs) like bevacizumab and sunitinib, even without concurrent use of antiresorptives. We hypothesized that certain AgIs exhibit antiresorptive activity in addition to their antiangiogenic effects, potentially influencing the pathophysiology of MRONJ. 52 five-week-old SD rats were randomized to receive vehicle (VEH), an oncologic dose of zoledronic acid (ZOL), or low (LD) and high doses (HD) of either an anti-VEGFA antibody or sunitinib (SU) for 10 days. We used the Schenk assay to assess the in vivo antiresorptive properties of these drugs/agents. We evaluated serum biomarkers of bone resorption (TRACP 5b) and formation (P1NP), pQCT variables of the femurs/tibias, and bone resorption/formation variables by bone histomorphometry at the distal femur metaphysis. ZOL reduced TRACP-5b levels, osteoclast number, and BFR while increasing vBMD, mineralized tissue volume, calcified cartilage volume, and bone volume. Both anti-VEGFA and SU decreased osteoclast number and increased calcified cartilage volume relative to total mineralized tissue volume, though to a lesser extent than ZOL. Anti-VEGFA (HD) also reduced TRACP-5b levels. Furthermore, both AgIs decreased P1NP levels, MAR, and bone elongation rate but increased growth cartilage thickness and induced physeal dysplasia. In conclusion, AgIs, particularly anti-VEGFA, exhibit significant yet milder antiresorptive activity compared to ZOL. They also affect bone formation, suggesting a complex mechanism that may play a role in the pathophysiology of MRONJ.

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.

First-line treatment of osteoporosis with osteoanabolic therapy: a new opportunity

Osteoporosis is a national health priority, and over six million Australians over the age of 50 years have poor bone health. Fragility fractures due to osteoporosis are associated with an increased morbidity and mortality risk and a high economic cost to the community. It is a chronic condition requiring long-term management. Despite notable advances in pharmacotherapy, large treatment gaps remain. Antiresorptive drugs have been the foundation of treatment; however, their efficacy wanes and rare adverse effects accumulate with prolonged use. Osteoanabolic drugs form new bone and can also restore deteriorated bone microarchitecture, in addition to increasing bone mineral density. Currently, antiresorptive drugs are used as first-line drugs for osteoporosis. However, recent studies have highlighted the superiority of anabolic drugs for fracture reduction over antiresorptives. Furthermore, for patients at very high risk or imminent risk of fracture, the use of sequential therapy with an osteoanabolic medication followed by an antiresorptive is superior to achieving optimal long-term bone health outcomes. This article will discuss the evidence supporting the anti-fracture benefits of osteoanabolic drugs, emphasising their benefits as first-line agents for osteoporosis. Challenges surrounding transitions between osteoanabolic and antiresorptive medications are also discussed, highlighting considerations for the optimal treatment sequence with a focus on recent updates to Australian prescribing recommendations and PBS requirements.

An update on the pharmacotherapy of osteoporosis

INTRODUCTION

Osteoporosis is a chronic metabolic bone disease characterized by progressive bone loss and structural deterioration, increasing fracture risk and morbidity. As the global population ages, its incidence is rising, underscoring the urgent need for more effective prevention and treatment strategies.

AREAS COVERED

This review synthesizes the latest evidence and guidelines from leading international societies, establishing a contemporary framework for osteoporosis pharmacotherapy. It emphasizes best practices and explores future directions in treatment optimization and fracture prevention.

EXPERT OPINION

To optimize outcomes, enhancing early detection, refining treatment strategies, and prioritizing patient-centered care are essential. Improving diagnosis through increased use of bone mineral density (BMD) assessments and identifying secondary causes are critical steps to addressing underdiagnosis, particularly in men. Pharmacotherapies play a vital role in management; while bisphosphonates serve as a cost-effective first-line treatment, denosumab and anabolic agents like Teriparatide and romosozumab are essential alternatives for high-risk patients. Future directions in osteoporosis management emphasize advancing treatment strategies through novel drug targets and innovative delivery systems, alongside personalized medicine approaches considering individual genetic and comorbidity profiles. Enhanced adherence strategies and further research into combination therapies and monitoring tools are crucial for improving prevention and treatment outcomes, ultimately reducing the fragility fracture burden worldwide.

Effect of clindamycin on human osteoblasts treated with zoledronate: An in vitro study

OBJECTIVE

The objective of this study was to determine the effects of combined treatment with clindamycin and zoledronate on the growth and differentiation of cultured human osteoblasts.

DESIGN

Human osteoblasts, obtained by primary culture from mandibular bone fragments, were cultured in the presence of 50 μM zoledronate, 150 μg/mL clindamycin, or the combination of both (zoledronate + clindamycin). The effect on cell proliferation was evaluated at 24 h by the MTT colorimetric method, using a spectrophotometer at 570 nm. The effect on differentiation was examined by measuring alkaline phosphatase (ALP) activity, and mineralization by the osteoblast was studied by staining with alizarin red. Real-time polymerase chain reaction (RT-PCR) was performed for gene expression analysis. Data were expressed as means±standard deviation, and analysis of variance was performed, applying Bonferroni correction when interactions were significant.

RESULTS

Treatment of osteoblasts with 50 μM zoledronate significantly reduced cell proliferation and differentiation and the gene expression of certain markers versus controls (p < 0.001). However, treatment with 150 μg/mL clindamycin significantly increased cell proliferation and differentiation and the gene expression of certain markers (p < 0.05). The combination of 150 μg/mL clindamycin and 50 μM zoledronate partially counteracted the loss of osteoblast proliferative and differentiation capacity caused by zoledronate.

CONCLUSION

Treatment with low-dose clindamycin can reverse the negative impact of zoledronate on osteoblast proliferation and differentiation. Follow-up animal studies and clinical trials are needed before topical clindamycin can be considered as a possible therapeutic resource for BP-treated patients who require a GBR procedure.

Risk assessment and drug interruption guidelines for dentoalveolar surgery in patients with osteoporosis receiving anti-resorptive therapy

Medication-related osteonecrosis of the jaw (MRONJ) is a rare and challenging complication of anti-resorptive therapy. This review addresses the critical issue of risk management in patients with osteoporosis who require dentoalveolar surgery while undergoing anti-resorptive therapy. Dental practitioners should be aware of these risks; however, they should not refuse treatment based solely on them. This review discusses the risks through five major factors: invasive dentoalveolar surgeries, concomitant oral infection, type of medication, duration of medication, and preoperative drug discontinuation. Additionally, we discussed the local factors associated with dental practices. Our review underscored the importance of personalized risk assessment, considering each patient's unique drug history and oral condition. Based on a comprehensive literature review and clinical evidence, we proposed specific guidelines for preoperative drug interruption tailored to different anti-resorptive agents. These recommendations aimed to balance osteoporosis management by minimizing the risk of MRONJ during oral surgical interventions and bridging the knowledge gap in managing patients with osteoporosis requiring dental care. This review will allow clinicians to improve their practice and optimize patient outcomes by providing evidence-based strategies.

Oral Ulceration With Bone Sequestration: Diagnostic Challenge, Management Strategy

Involving ulceration over non-vital bone without osteonecrosis factors, Oral Ulceration with Bone Sequestration (OUBS) is underreported in the scientific and medical literature. We hope that our study will: (i) help health professionals in diagnosing and managing OUBS, (ii) encourage them to publish their experiences, and (iii) inspire researchers to develop models to address unresolved questions about this condition.

Risk Factors Influencing Medication-Related Osteonecrosis of the Jaws (MRONJ) Following Dental Extraction Among Osteoporotic Patients in Taiwan

AIM

Antiresorptive therapy (ART) is commonly used in osteoporotic patients to prevent bone loss. This retrospective cohort study aimed to identify the risk factors associated with medication-related osteonecrosis of the jaw (MRONJ) in osteoporotic patients receiving dental extraction during ART.

MATERIALS AND METHODS

Data were collected from 937 patients with 1067 dental extractions conducted between January 2003 and May 2022, including 519 patients on oral alendronate, 276 on denosumab, and 172 on zoledronate. Multivariate logistic regression analysis was employed to assess potential risk factors.

RESULTS

Regression model analysis revealed older age (AOR 1.09 per year; 95% CI, 1.06-1.12) and drug treatment exceeding 24 months (AOR 2.07; 95% CI, 1.29-3.30) as significant risk factors. A drug interruption of 3 or more months prior to tooth extraction lowered MRONJ risk (AOR 0.11; 95% CI, 0.07-0.17). Stratified by drug type, denosumab users had significantly lower risk of MRONJ after extraction (AOR 0.14; 95% CI, 0.07-0.27) compared to those on other medications. Factors of drug duration ≥ 24 months, < 3 months of interruption, and posterior mandibular tooth extraction posed the highest synergistic MRONJ risk (AOR 80.29; 95% CI, 33.05-195.09).

CONCLUSION

Our results suggest an association between a three-month ART interruption prior to tooth extraction and reduced MRONJ risk, especially in long-term ART patients undergoing posterior mandibular extractions. However, these findings require validation through prospective randomized controlled trials.

CLINICAL RELEVANCE

Scientific Rationale for Study: The study fills crucial knowledge gaps regarding MRONJ risks in osteoporotic patients undergoing dental extraction during antiresorptive therapy (ART), providing a foundation for informed clinical decisions.

PRINCIPAL FINDINGS

Noteworthy findings include elevated MRONJ risk with older age and prolonged ART, the protective effect of a 3-month ART interruption, and denosumab users showing significantly reduced postextraction MRONJ risk.

PRACTICAL IMPLICATIONS

Implementing a 3-month ART interruption before dental extraction is recommended to reduce MRONJ occurrences.

Bifidobacterium longum increases serum vitamin D metabolite levels and modulates intestinal flora to alleviate osteoporosis in mice

The elderly population is prone to osteoporosis, owing to the deterioration of the skin, liver, and kidney functions. Vitamin D (VD) supplementation has a limited effect, and VD deficiency is mostly treated with medication. Several studies have shown that the gut microbiota alters intestinal VD metabolism and that probiotic supplements can influence circulating VD levels. Therefore, in the present study, we screened a strain of Bifidobacterium longum FSHHK13M1 that can increase the level of VD metabolites in the fermented supernatant species in vitro by modeling fecal bacterial fermentation. The results showed that FSHHK13M1 intervention significantly increased the serum levels of 1,25-dihydroxy VD and osteocalcin. It activated the expression of the VDR, OPG, Wnt10b/β-catenin, and Runx2/Osterix pathways and inhibited the expression of RANKL/RANK pathway. Furthermore, there was an enhancement in the quantity of bone trabeculae and the proportion of bone volume. Concurrently, the gut microbiota in mice with osteoporosis exhibited signs of imbalance. FSHHK13M1 intervention increased the relative abundance of specific bacteria, such as Faecalibaculum rodentium, Limosilactobacillus fermentum, Bifidobacterium pseudolongum, and Akkermansia muciniphila. These results suggest that B. longum FSHHK13M1 alleviates retinoic acid-induced osteoporosis symptoms by modulating related genes, regulating the intestinal flora and increasing the level of active VD.IMPORTANCEOsteoporosis is a systemic metabolic disease in which the patient's bone mass decreases for a variety of reasons, and the microstructure of the bone tissue is altered, leading to an increase in bone brittleness and susceptibility to fracture. Osteoporosis is almost always present in the elderly population, and fractures from falls are an important predisposing factor for mortality risk in the elderly population. Supplementation is quite limited for them as they are not able to utilize vitamin D well due to declining liver, kidney, and skin functions. In the present study, a strain of Bifidobacterium longum probiotic was found to increase the levels of the active form of vitamin D and ameliorate osteoporosis. This may play an important role in preventing osteoporosis and reducing fracture risk in the elderly.

Prognostic indicators in medication-related osteonecrosis of the jaw: A systematic review and meta-analysis

Modulation of bone turnover by antiresorptive agents impairs wound healing of jaw bones, and can result in an adverse event termed medication-related osteonecrosis of the jaw (MRONJ). In recent years, the prevalence, risk factors, and prevention strategies for MRONJ have been extensively investigated, but only few studies have focused on its treatment outcome, and the proposed prognostic factors have varied greatly. We systematically reviewed the prognostic factors in patients undergoing treatment for MRONJ. In total, 33 studies met the inclusion criteria out of 1,388 screened citations. For analysis, we grouped the prognostic factors into five categories as follows: medication-related, underlying conditions, lesion-related, serum markers, and treatment modalities. Discontinuation of antiresorptive therapy was a medication-related factor significantly associated with better treatment outcomes. Regarding underlying conditions, malignancy, especially multiple myeloma, was associated with worse treatment outcomes. Among lesion-related factors, better treatment outcome was noted for maxillary lesions and lesions with sequestrum formation. By contrast, lesions of advanced stages and those with periosteal reaction had poor treatment outcomes. Regarding treatment modality, surgical therapy was associated with a better chance of healing. Results of our meta-analysis helped identify prognostic indicators of MRONJ and will assist in decision-making in the clinical setting. Based on our results, surgeons may have a better cognitive context to discuss treatment options with patients. Additionally, our findings provide convincing evidence for physicians to consider postponing antiresorptive therapy in patients with MRONJ lesions.

Development of a Medication-Related Osteonecrosis of the Jaw Prediction Model Using the FDA Adverse Event Reporting System Database and Machine Learning

Background: Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious adverse event. Herein, we conducted a quantitative structure-activity relationship analysis using the U.S. Food and Drug Administration Adverse Drug Reaction Database System (FAERS) and machine learning to construct a drug prediction model for MRONJ induction based solely on chemical structure information. Methods: A total of 4815 drugs from FAERS were evaluated, including 70 and 139 MRONJ-positive and MRONJ-negative drugs, respectively, identified based on reporting odds ratios, Fisher's exact tests, and ≥100 total adverse event reports. Then, we calculated 326 chemical structure descriptors for each drug and compared three supervised learning algorithms (random forest, gradient boosting, and artificial neural networks). We also compared the number of chemical structure descriptors (5, 6, 7, 8, 9, 10, 20, and 30 descriptors). Results: We indicated that the MRONJ prediction model using an artificial neural network algorithm and eight descriptors achieved the highest validation receiver operating characteristic curve value of 0.778. Notably, the total polar surface area (ASA_P) was among the top-ranking descriptors, and MRONJ-positive drugs such as bisphosphonates and anticancer drugs showed high values. Our final model demonstrated a balanced accuracy of 0.693 and a specificity of 0.852. Conclusions: In this study, our MRONJ-inducing drug prediction model identified drugs with polar surface area properties as potential causes of MRONJ. This study demonstrates a promising approach for predicting MRONJ risk, which could enhance drug safety assessment and streamline drug screening in clinical and preclinical settings.

68Ga PSMA PET/CT and 18F FDG PET/CT Findings in Osteonecrosis of the Jaw Induced by Denosumab

Breast cancer, prostate cancer, kidney cancer, multiple myeloma, osteoporosis, and the use of antiresorptive and antiangiogenic drugs are risk factors for osteonecrosis of the jaw (ONJ). Denosumab is a Receptor activator of nuclear factor kappa-Β ligand antagonist monoclonal antibody that inhibits the differentiation and function of osteoclasts over osteoblasts. It is an antiresorptive drug used to reduce the development of skeletal events in solid cancers. Denosumab-induced ONJ is a rare condition, occurring in 0% to 4.6% of cases. In this case, the findings of 68Ga prostate specific membrane antigen (PSMA) positron emission tomography (PET)/Computed Tomography (CT) and 18F Fluorodeoxyglucose (FDG) PET/CT are presented in a man with metastatic castration-resistant prostate cancer who developed ONJ due to denosumab use.

["Paradoxical fractures": pathological fractures under anti-osteoporotic and antirheumatic treatment]

Pathological fractures under anti-osteoporotic and antirheumatic treatment are very rare events. Nevertheless, atypical femoral fractures occur during antiresorptive treatment with bisphosphonates or denosumab, the latter especially in patients previously treated with bisphosphonates. Treatment with teriparatide can be helpful. While glucocorticoids have a well-known influence on the development of osteoporosis and thus also fractures, the probably unproblematic use in the low-dose range has so far found little acceptance. Methotrexate-induced osteopathy is also a rare phenomenon but is now well accepted and known. There are several approved medications for the treatment of glucocorticoid-induced osteoporosis and for methotrexate-induced osteopathy, discontinuation of methotrexate is particularly essential.

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.

Real-world study of medication-related osteonecrosis of the jaw from 2010 to 2023 based on Food and Drug Administration Adverse Event Reporting System

Medication-related osteonecrosis of the jaw (MRONJ) is a rare and severe adverse drug reaction (ADR) commonly seen in people taking drugs prescribed for metastatic cancer and osteoporosis. Prior studies only analyzed this ADR utilizing the public database Food and Drug Administration Adverse Event Reporting System (FAERS) by different stages (2010-2014, 2015-2021); a more comprehensive study is needed to analyze the MRONJ cases and the associated drugs from a longer time span. We conducted a retrospective pharmacovigilance analysis for all reported MRONJ cases between 2010 and 2023 in FAERS, using preferred terms and the primary suspect drug as searching conditions. Thus, this study aimed to analyze the MRONJ cases and the associated drugs more comprehensively. The reporting odds ratios (RORs) and 95% CIs were calculated for each queried drug. To distinguish the signal levels, we calculated the expected information component (EIC) and its 95% CI, using the Bayesian confidence propagation neural network (BCPNN) methods. We identified 22 846 MRONJ cases. A total of 15 drug classes including 30 suspect drugs showed different positive signal levels; among these drugs, 8, 5, and 17 had strong, medium, and weak intensity signals (+++, ++, and +), respectively. Drug classes involved bisphosphonate, RANKL inhibitor, radiotherapy drug, monoclonal antibody for cancer, corticosteroid, tyrosine kinase inhibitor, mammalian target of rapamycin inhibitor, aromatase inhibitor, cyclin-dependent kinase 4/6 inhibitor, immunomodulator, microtubule inhibitor, selective estrogen receptor modulator, sclerostin monoclonal antibody, estrogen receptor antagonist, and cytotoxic drug. Bisphosphonate, RANKL inhibitor, and radiotherapy drug exhibited higher risk than other classes with higher ROR or EIC 95% CI lower limit. Females had higher MRONJ incidence than males, and the mean age was 67.33 ± 11.71 yr. Compared with previous research, this study identified more drug classes and more novel medications with positive MRONJ signals that warrant further attention.

Novel standardized method for inducing medication-related osteonecrosis of the jaw in rats and precise quantitative assessment of pathological outcomes

Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication of antiresorptive therapies, characterized by delayed healing, bone necrosis, and infection following dental procedures. Progress in the understanding of its pathophysiology has been hindered by the lack of standardized animal models. Existing models involving first molar or multiple molar extractions disrupt anatomic landmarks and face technical challenges, such as retained root fragments and inconsistent surgical procedures, which reduce reproducibility. To address these limitations, we developed a novel rat MRONJ model using maxillary second molar extraction combined with standardized palatal gingiva resection. By preserving the adjacent first and third molars, anatomic landmarks were retained, enabling precise and reproducible evaluations. The modified extraction technique incorporating wedge insertion improved the success rate and minimized root fractures. Notably, our findings revealed that suppressed bone metabolism in the MRONJ model inhibited natural tooth movement observed in the control group, highlighting a unique pathologic hallmark of MRONJ. The model effectively reproduced MRONJ-specific features, including persistent bone exposure, impaired bone healing, necrotic bone formation, and inflammation. Three-dimensional micro-computed tomography and histologic analyses provided robust and quantitative assessments of bone pathology. By integrating anatomic standardization and precise quantitative assessments, this model addresses the key limitations of previous approaches. It also provides a reliable platform for investigating the pathogenesis of MRONJ and for assessing preventive and therapeutic strategies. This approach contributes to translational research and holds promise for improving clinical outcomes.

Arcyriaflavin A Alleviates Osteoporosis by Suppressing RANKL-Induced Osteoclastogenesis

Osteoclasts (OCs) are important therapeutic targets in the treatment of osteoporosis. The aim of this study was to explore a novel therapeutic approach for osteoporosis using Arcyriaflavin A (ArcyA), a natural compound derived from the marine invertebrate Eudistoma sp. We systematically evaluated the effects of ArcyA on OC differentiation and function in mouse models using molecular biology assays, cellular function analyses and in vivo animal experiments. We also evaluated the efficacy of ArcyA in human cells. The TRAP staining results provide the first clear evidence of the drug's inhibitory effect, whereby the administration of ArcyA led to a significant reduction in TRAP-positive cells compared to the control group at concentrations that were non-toxic to bone marrow macrophages. Meanwhile, a significant reduction in the number of multinucleated giant cells with more than ten nuclei was observed. Furthermore, similar TRAP staining results were reproduced in human OCs, suggesting that ArcyA has the same effect on OCs derived from human PBMCs. At the molecular level, ArcyA treatment resulted in the downregulation of genes relevant to OC differentiation (NFATc1, cFos and TNFrsf11α), fusion and survival (DCstamp and ATP6v0d2) and resorption function (CTSK, MMP9, integrin β3 and ACP5). A western blot analysis of the corresponding proteins (NFATc1, cFos, CTSK and integrin β3) further confirmed the PCR results. Furthermore, ArcyA-treated OCs produced significantly fewer resorption pits, indicating suppressed bone resorption activity. Consistent with this, in vivo experiments using an ovariectomy (OVX)-induced osteoporosis mouse model showed that ArcyA treatment significantly alleviated bone loss. Mice in the treatment groups had higher BV/TV values, and this therapeutic effect was enhanced in a dose-dependent manner. In addition, our research also showed that IκB could be a potential target for the inhibitory effect of ArcyA. In conclusion, these findings suggest that ArcyA has significant therapeutic potential for the treatment of osteoporosis by inhibiting osteoclastogenesis and bone resorption. Further studies are warranted to explore its clinical applications.

Bone scintigraphy and positron emission tomography in the early diagnosis of MRONJ

Objectives

The aim of this study is to evaluate the bone scintigraphy (BS) and positron emission tomography (PET) in the early diagnosis of medication-related osteonecrosis of the jaws (MRONJ) and their possible use in the identification of patients at risk for MRONJ.

Material and methods

Thirty-one patients treated with ONJ-related drugs and who had undergone BS or PET for the evaluation of bone lesions were included in the study. The jaws of each patient were divided into four areas. For each area, the presence of pathological tracer uptake was evaluated and related to the eventual MRONJ development. Sensitivity, specificity, and predictive values of both techniques were determined. The latency from the finding of pathological tracer uptake in BS or PET to the clinical diagnosis of MRONJ and the odds ratio were also calculated.

Results

Sensitivity and specificity of BS for MRONJ prediction were, respectively, 83.3 and 87.5%. Positive and negative predictive values were, respectively, 73.2 and 92.8%. The odds ratio was 35. Sensitivity of PET was 33.3%, specificity was 94.9%, and positive and negative predictive values were 70.0 and 80.0%, respectively. The odds ratio was 9.333. All values were statistically significant.

Conclusions

BS and PET may be accurate techniques for an early prediction of MRONJ.

Evolving strategies for osteoporosis management in postmenopausal women: From tradition to innovation

Osteoporosis is a chronic condition primarily affecting postmenopausal women, significantly impacting their well-being and quality of life. Traditional treatment approaches include medications, vitamins, and exercise, but there is a growing interest in alternative therapies that enhance bone health. This review was conducted by searching multiple databases, including PubMed, Medline, and Google Scholar, for studies related to osteoporosis treatment. Articles focusing on both traditional therapies such as bisphosphonates, calcium, and vitamin D supplementation, and newer advancements like vibration therapy and bone-building devices such as Osteoboost were included. Traditional treatments, such as vitamin supplementation, exercise, and bisphosphonates, remain foundational in osteoporosis management, helping to maintain bone density and reduce fracture risks. Recent developments, including vibration therapy and Osteoboost, show promising results in bone regeneration without the use of medication. While traditional therapies continue to play an essential role, advancements like vibration therapy present novel alternatives for managing osteoporosis. Further research is necessary to optimize these approaches, ensuring they maximize benefits while minimizing risks, ultimately improving patient outcomes and quality of life.

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.

Medication-Related Osteonecrosis Successfully Treated With Hyperbaric Oxygen Therapy and Conservative Treatment: A Case Report

Medication-related osteonecrosis of the jaws (MRONJ) is a major side effect of the antiresorptive drugs used in treating patients with osteoporosis and cancer. MRONJ appears as prolonged inflammation affecting the maxilla or mandible, with necrotic bone exposure and intraoral and extraoral fistulas. According to previous studies, surgery for this condition is highly beneficial. However, extensive surgical treatment generally overburdens patients with MRONJ, who often already suffer from other diseases such as cancer; therefore, further consideration must be given to their overall condition. Herein, we present the case of an elderly patient with extensive MRONJ who was successfully treated with hyperbaric oxygen therapy and conservative treatment.

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.

Pharmacovigilance study of immunomodulatory drug-related adverse events using spontaneous reporting system databases

The aim of this study was to evaluate the country-specific reporting status profile of immunomodulatory drugs (IMiDs)-related adverse events (ImrAEs) in real-world clinical practice, using data from the Japanese Adverse Drug Event Report (JADER) and Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) databases. Immunomodulatory drugs, including thalidomide and its derivatives, are a new class of anticancer and anti-inflammatory drugs. IMiD risk management programs have instituted sufficient measures to prevent fetal effects but do not address adverse effects experienced by patients themselves. To date, no study has compared ImrAE profiles across countries. Adverse events were defined using the preferred terms in the Medical Dictionary for Regulatory Activities. The number of reported adverse events related to IMiDs in each country (the United States and Japan) was investigated. In both Japan and the United States, myelosuppression, pneumonia, and neuropathy peripheral have been reported as adverse events suspected to be associated with IMiDs. Adverse event profiles differed between the countries. The number of adverse event reports for thalidomide increased transiently in the United States in 2008 following the multiple myeloma indication, and then exhibited a downward trend. The number of adverse event reports for lenalidomide and pomalidomide has increased in the United States since their launch. The number of transient reports increased in Japan in 2015, when pomalidomide was launched. In this study, the profile of ImrAEs was revealed using the FAERS and JADER databases. Our comparative safety study indicated the importance of comparing the safety profiles of IMiDs using post-marketing real-world data. It is important to focus on the adverse events experienced by patients taking IMiDs, as well as the effects of IMiDs on fetuses.

Adult Chicken Bone-Derived Components Reverse the Impaired Calcium Homeostasis and Bone Mass in Mice Lacking 1,25(OH)2D3-VDR Signaling

Female adult chickens, known as laying hens, possess a distinctive bone structure in the intracortical region, which is responsible for storing calcium. Given the cyclical nature of calcium storage and demand during the egg-laying cycle, the medullary bone of laying hens plays a crucial role in maintaining calcium homeostasis. In this study, we examined the potential of orally administered components derived from adult chicken bones to improve calcium homeostasis and bone mass in mice. Samples from adult chickens and young chickens without egg-laying experience were prepared by pressing meat parts, including bones, and administered to wild type (WT) and vitamin D receptor knockout (VDRKO) mice respectively. The phenotypes observed in VDRKO mice, such as severe reductions in serum calcium concentration and bone mass, were normalized in mice fed the adult chicken bone-containing diet to the same extent as in WT mice. These effects were not observed in mice fed a young chicken bone-containing diet. The adult chicken bone-containing diet increased apparent calcium absorption in VDRKO mice compared to other dietary groups. To determine the effects on bone metabolism, osteoclasts activity was evaluated by histological measurements and the quantification of serum osteoclast marker, and it was restored by the adult chicken bone-containing diet. In addition, the treatment of adult chicken bone-derived components increased osteoclasts differentiation in vitro from cultured bone marrow macrophage. These results show that adult chicken bone-derived components improve calcium and bone homeostasis in mice lacking vitamin D action through combined effects that target calcium metabolism and bone turnover.

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.

The issue with incidence: a scoping review of reported medication-related osteonecrosis of the jaws (MRONJ) incidence around the globe

Background

Medication-related osteonecrosis of the jaws (MRONJ) can be a debilitating condition which is challenging to manage. While vast literature exists surrounding MRONJ, many studies have small participant numbers and are heterogeneous in design, leaving unanswered questions and making evidence-based practice challenging.

Objective

Provide an overview of recent MRONJ incidence data, over a 5-year period, identify potential issues in reporting MRONJ cases and propose changes for future reporting.

Eligibility criteria

Studies with original data regarding MRONJ incidence published from 2015 to 2020.

Sources of evidence

A search was conducted on MEDLINE Ovid, the National Library of Medicine's bibliographic database, using a combination of medical subject headings (MeSH) and free text terms and run on 29 April 2021.

Charting method

Each title was hand-screened, and the abstract/article in full was reviewed to establish suitability for inclusion by two authors. Data extraction by two reviewers included author, year of publication, study design, population-cancer/osteoporosis/both/other, description of population, sampling method, exclusion criteria, single centre Y/N, reported rate of MRONJ cases/number of participants, details of diagnosis and diagnostic criteria, duration of follow-up and location of study.

Results

The initial search returned 1186 titles, detailed screening and inclusion of additions resulted in 92 articles for data extraction. Mean incidence of MRONJ across all studies was 4.34% (median 2.42%, range 0% to 31.80%). The mean incidence based on patient group was oncology 6.22% (32 954 participants), osteoporosis 0.58% (498 443 participants), oncology and osteoporosis 7.21% (54 7651 participants) and other, including autoimmune, inflammatory and other bone conditions, 2.55% (4487 participants). Further analysis showed incidence influenced by study size (>500 participants), diagnostic criteria used, location of study and other factors.

Conclusion

Heterogeneity in studies reporting MRONJ incidence impacts results and conclusions. Standardised, contemporaneous reporting of MRONJ cases would eliminate this variation and provide valuable insight into the epidemiology, natural history and outcomes of these patients, supporting evidence-based management and service provision of patients affected.

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).

Evaluating the efficacy of surgical and non-surgical treatment modalities in the management of medication-related osteonecrosis of the jaw: A retrospective study

OBJECTIVE

Our primary goal is to examine the efficacy of surgical and non-surgical therapy in treating Medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

Retrospective data were obtained from patients treated between 1st June 2011 to 1st December 2021. Included patients were classified into surgical and non-surgical therapy. The primary outcome measure is to assess the treatment's effect on the disease stage. Secondary outcome measures include the time to mucosalisation, exposed bone area, presence of infection, improvement in pain and paraesthesia, and qualitative assessment of radiographic presentation.

RESULTS

48 patients with 57 MRONJ sites were included in this study. The mean follow-up duration was 30.2 months (SD = 25 months). Neither smoking, alcohol use, nor any of the comorbidities significantly affected the treatment outcome of the disease. The drug administration mode influenced the treatment outcome (p = 0.00413). MRONJ lesions that were treated with surgery displayed statistically significant improvement (p = 0.018) in disease staging. The time taken for mucosalisation was faster after surgery (p = 0.00052). Regarding secondary outcomes, surgical therapy resulted in a significant improvement in the resolution of purulence (p = 0.041). No significant difference was observed for radiographic healing, exposed bone area, or pain.

CONCLUSION

Surgical therapy results in significant clinical improvement of MRONJ lesions compared to non-surgical therapy. However, non-surgical therapy can effectively prevent disease progression. Depending on the therapeutic goals, both treatment modalities are appropriate for managing MRONJ.

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.

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.

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.

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.