Response to comments on "diagnosis and management of osteoporosis of the jaw: a systematic review and international consensus"

Predictive factors for refractory stage I and II anti-resorptive agent-related osteonecrosis of the jaw

OBJECTIVES

We aimed to predict the possibility of patients with stage I and II anti-resorptive agent-related osteonecrosis of the jaw (ARONJ) developing resistance to our treatment protocol by evaluating their clinical and imaging factors.

MATERIALS AND METHODS

We enrolled 58 patients with ARONJ who underwent imaging modality. As objective variables, we considered the healing, stage-down, and stable stages as successful outcomes, and the stage-up stage as resistant-to-treatment. As explanatory variables, we investigated the clinical and imaging factors. Furthermore, we examined stage-down as an improvement outcome to compare with the stable and stage-up stages, which were considered as no-improvement outcomes. We conducted unpaired between-group comparisons on all explanatory variables using χ² tests for independence.

RESULTS

Among 58 patients, the treatment was successful in 53 (91.4%); however, the disease was resistant in five (8.6%). Among the clinical factors, the resistant patients had a longer duration of administration of bone-modifying agents (BMAs) (cut-off: 1251 days, p = 0.032, odds ratio = 11.2, 95% confidence interval 1.115-122.518). In addition, the target disease that was being treated bone metastasis of malignant tumor was the only significant refractory factor (p = 0.024, OR: 3.667 95% CI 1.159-11.603) CONCLUSIONS: A combination of metabolic and morphological imaging modalities may be useful for oral surgeons to evaluate the disease activity and predict course of refractory ARONJ.

Odontogenic infection and antiresorptive agent-related osteonecrosis of the jaw with facial subcutaneous abscess formation: A retrospective clinical study of difficult-to-diagnose cases

OBJECTIVE

The objective of this study was to analyze difficult-to-diagnose cases of odontogenic infection and antiresorptive agent-related osteonecrosis of the jaw (ARONJ) with facial subcutaneous abscesses by otolaryngologists.

METHODS

The study was conducted in the department of otolaryngology of a university hospital. Seven patients exhibiting odontogenic infection and ARONJ with facial subcutaneous abscesses diagnosed at the department of otolaryngology in our hospital from January 2008 to December 2018 were included in the study. We investigated the following information obtained from the patients: clinical department for initial treatment, sex, age, offending tooth, causative disease, site of the fistula, symptoms, methods of diagnoses, and therapy.

RESULTS

Odontogenic infection with facial subcutaneous abscess formation can occur in individuals in a wide range of age groups; however, the pathological manifestations of ARONJ are often observed in older women, frequently at the chin and accompanied by nodules and pain in the adjacent teeth. Computed tomography and orthopantomography are useful for diagnosis and are especially indicated for patients under long-term follow-up or with frequent recurrences. Magnetic resonance imaging, cytodiagnosis, and histological analysis might be necessary to exclude the possibility of tumors. Management of such facial subcutaneous abscesses comprises dental treatment and infection control, and f surgical removal of the abscess is usually not required. Treatments such as sequestrectomy and sitafloxacin administration are useful for patients with ARONJ.

CONCLUSION

Our results demonstrated that for patients with facial subcutaneous abscesses, involvement of odontogenic infection and ARONJ should be considered.

Relationships of opacification in the nasal sinuses, rhinosinusitis, and antiresorptive agent-related osteonecrosis of the jaw

OBJECTIVE

Bone turnover suppression agents are widely used for prophylaxis of bone metastases from cancer and osteoporosis; the occurrence of their side effect, antiresorptive agent-related osteonecrosis of the jaw (ARONJ), has been increasing. We investigated the relationships between opacification in the nasal sinuses, rhinosinusitis, and ARONJ based on data obtained from oral surgeons.

METHODS

We examined 132 patients who had been clinically diagnosed with ARONJ based on clinical observations; all patients had undergone treatment at the Departments of Otorhinolaryngology and Oral Surgery. In 16 of the 132 patients, we confirmed a diagnosis of osteonecrosis of the upper jaw and the presence of ipsilateral opacification of the maxillary sinus. We analyzed the data of these 16 patients in detail.

RESULTS

Five of the 16 patients had some nasal symptoms and had been diagnosed with rhinosinusitis. The opacification of the rhinosinuses improved, partially improved, and remained unchanged after treatment in 10, three, and two patients, respectively; notably, imaging assessment could not be conducted after treatment in one case.

CONCLUSIONS

Although there is no consensus regarding the treatment of sinusitis accompanying ARONJ, attempts to improve the causal foci and conservative treatment may offer favorable results; thorough investigation is necessary in refractory cases before determining the use of surgery.

Changes of serum IGF-1 and ET-1 levels in patients with osteoporosis and its clinical significance

Objective:

To investigate the correlations of levels of serum insulin-like growth factor-1 (IGF-1) and endothelin-1 (ET-1) with cytokines including interleukin (IL)-18, IL-6 and high-sensitivity C-reactive protein (hs-CRP) and bone material density in patients with osteoporosis d.

Methods:

Eighty patients with osteoporosis who were treated in our hospital from April 2016 to October 2017 were selected as observation group, and 60 healthy elderly people who received physical examination in our hospital in the same period were selected as control group. The serum levels of IGF-1 and ET-1 were detected using enzyme-linked immunosorbent assay. The bone material density of the lumbar vertebra, tibial neck and Ward’s triangle of every research subject was measured using dual-energy x-rays absorptiometry. The correlations between variables were analyzed using Pearson correlation analysis.

Results:

The level of IGF-1 in the observation group was lower than that in the control group, and the level of ET-1 in the observation group was higher than that in the control group (P<0.05). The levels of interleukin (IL)-18, IL-6 and high-sensitivity C-reactive protein (hs-CRP) in the observation group were significantly higher than those in the control group (P<0.05). Bone mineral density of lumbar vertebra, tibial neck and Ward triangle in the observation group was significantly lower than that in the control group (P<0.05); the IGF-1 level of osteoporosis patients was negatively correlated with IL-18, IL-6, hs-CRP levels and positively correlated with bone mineral density; the ET-1 level was positively correlated with IL-18, IL-6, hs-CRP levels and negatively correlated with bone mineral density.

Conclusion:

Patients with osteoporosis have decreased level of IGF-1 but increased level of ET-1, and they are closely related to cytokines and bone mineral density and may participate in the pathogenesis of osteoporosis.

Oral ulceration with bone sequestration: Retrospective study of eight cases and literature review

OBJECTIVE

Oral ulceration with bone sequestration (OUBS) describes a site-specific intraoral ulcer that covers exposed, non-vital bone in patients lacking any etiological factor known to induce osteonecrosis. We aimed to conduct a retrospective study of eight new cases of OUBS and review the literature.

SUBJECTS AND METHODS

This is a retrospective study of OUBS cases, diagnosed and managed during 2007-2017. Inclusion criteria were the presence of oral ulcer with exposed non-vital bone at sites of bone prominence and the absence of any factor known to cause osteonecrosis. The English literature was reviewed on original OUBS cases.

RESULTS

Eight patients (5 males and 3 females, aged 27-75 years) were diagnosed with OUBS during years 2007-2017. Four cases involved the mandibular mylohyoid ridge, one a mandibular anterior exostosis and three the maxillary buccal/palatal exostoses. Exposed bone was removed under local anesthesia, resulting in complete healing in all cases. The literature review yielded 32 OUBS cases in the mandible.

CONCLUSION

Oral ulceration with bone sequestration is a distinct, probably under-reported rather than rare clinical entity that should be regarded the provisional diagnosis in case of an oral ulcer covering exposed, non-vital bone at sites of bone prominence in patients lacking any etiological factor known to induce osteonecrosis.

The Dental Management of Patients at Risk of Medication-Related Osteonecrosis of the Jaw: New Paradigm of Primary Prevention

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction of antiresorptive and antiangiogenic agents; it is a potentially painful and debilitating condition that can considerably affect the quality of life of patients. Furthermore, even if its epidemiology and pathogenesis have still not been fully clarified, several risk factors related to MRONJ have been recognized in prevention protocols. Three main risk factors are as follows: (i) the type of ONJ-related medications: antiresorptive (e.g., Bisphosphonates, Denosumab) and antiangiogenic drugs (e.g., Bevacizumab, Sunitinib); (ii) the category of patient at MRONJ risk: cancer versus non-cancer patient; (iii) the typologies and timing of dental treatments (e.g., before, during, or after the drug administration). The aim of this paper is to describe the new paradigm by the Italian Society of Oral Pathology and Medicine (SIPMO) on preventive dental management in patients at risk of MRONJ, prior to and during/after the administration of the aforementioned ONJ-related drugs. In reducing the risk of MRONJ, dentists and oral hygienists are key figures in applying a correct protocol of primary prevention for pre-treatment and in-treatment patients. However, the necessity of a multidisciplinary standardized approach, with a sustained dialogue among specialists involved, should be always adopted in order to improve the efficacy of preventive strategies and to ameliorate the patient's quality of life.