Uncertainty of current algorithm for bisphosphonate-related osteonecrosis of the jaw in population-based studies: a systematic review

No increased risk of osteonecrosis of the jaw in osteoporotic patients with dental implants: a nationwide cohort study

OBJECTIVES

The occurrence of implant-associated osteonecrosis of the jaw (ONJ) has been reported in osteoporotic patients, particularly in association with bisphosphonate therapy. This study aimed to investigate the risk of implant surgery and implant presence for ONJ occurrence in osteoporotic patients longitudinally.

METHODS

Based on Korean National Health Information Database, subjects over the age of 65 who were diagnosed with osteoporosis between July 2014 and December 2016 were included. The implant group included subjects who had undergone dental implant surgery between January 2017 and December 2017, while the control group included those who had no history of dental implants. The primary outcome was the occurrence of ONJ, and the date of final follow-up was December 2020.

RESULTS

A total of 332,728 subjects with osteoporosis were included in the analysis: 83,182 in the implant group and 249,546 in the control group. The risk of ONJ among those who had undergone implant surgery (risk of implant surgery-associated ONJ) was not higher than that among those without implant surgery. The risk of ONJ among those with implants (risk of implant presence-associated ONJ) was lower than that among those without implants. Even in subjects with a history of bisphosphonates, steroids, periodontitis, or tooth extraction, those who had undergone implant surgery or had implants did not have a higher ONJ risk than those who had not undergone surgery or did not have implants; rather, they showed a lower risk.

CONCLUSIONS

The results may suggest that dental implants are not associated with an increased risk of ONJ. A further study on whether dental implants are associated with lower ONJ risk is needed.

CLINICAL RELEVANCE

Dental implants did not increase the risk of ONJ development in osteoporotic patients, even with a history of bisphosphonates. This may suggest that the risk profiles for ONJ occurrence between selective insertion of dental implants and other dentoalveolar surgery associated with infectious conditions are different.

Association between periodontal disease, tooth extraction, and medication-related osteonecrosis of the jaw in women receiving bisphosphonates: A national cohort-based study

BACKGROUND

We investigated whether periodontal diseases contribute to the development of medication-related osteonecrosis of the jaw (MRONJ) in addition to tooth extraction, which is a major risk factor for MRONJ occurrence.

METHODS

This retrospective, nationwide cohort study was performed using South Korea's National Health Insurance Service database on women aged > 50 years who took bisphosphonates for at least 1 year between 2010 and 2015. MRONJ, periodontal disease, and tooth extraction were defined using the claims data.

RESULTS

Among the 27,168 patients analyzed, the incidence of confirmed MRONJ was significantly higher in the periodontal disease group (0.58%) than in the nonperiodontal disease group (0.31%). While extraction alone showed an increased risk of MRONJ development (hazard ratio [HR] = 1.61, 95% confidence interval [CI]: 0.74-3.52), periodontal disease without tooth extraction also indicated a similar risk (HR = 1.68, 95% CI: 0.86-3.28); when a history of both periodontal disease and tooth extraction was present, the HR significantly increased to 2.55 (95% CI: 1.41-4.64).

CONCLUSIONS

The risk of MRONJ increased significantly when tooth extraction was performed in patients diagnosed with periodontal disease; therefore, periodontal diseases should be proactively managed in patients taking bisphosphonates.

Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations

Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.

Medication-Related Osteonecrosis of the Jaw in Cancer Patients: Result from the OneFlorida Clinical Research Consortium

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but severely debilitating drug-induced bone disorder in the jawbone region. The first MRONJ was reported in 2003 after bisphosphonate (BP) exposure. Recently, other drugs, such as receptor activator of NF-κB ligand (RANKL) inhibitor denosumab and antiangiogenic agents, were also associated with MRONJ. The purpose of this study was to evaluate the incidence and risk factors for MRONJ related to BPs or denosumab in cancer patients in real-world clinical settings using data from the OneFlorida Clinical Research Consortium. We queried the electronic health records of participants with prescriptions of intravenous (IV) BPs or denosumab between January 1, 2012, and September 1, 2021, in the OneFlorida Consortium. Time to MRONJ diagnosis was evaluated using the Kaplan-Meier method, and Cox regression analysis was performed to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for MRONJ. A total of 5689 participants had one or more prescriptions of IV BP or denosumab within this study period and were included in this study. Among these participants, 52 (0.9%) had a diagnosis of MRONJ. The overall rate of MRONJ was 0.73%, 0.86%, and 3.50% in the cancer patients treated with IV BPs, denosumab, and sequential IV BPs and denosumab, respectively. The risk of MRONJ was similar in participants treated with denosumab alone compared to those treated with IV BPs alone (HR: 1.25, 95% CI: 0.66-2.34, p = .49). Patients with sequential prescription of IV BP and denosumab were at much higher risk for MRONJ, with an adjusted HR of 4.49, 95% CI of 1.96-10.28, p = .0004. In conclusion, in real-world clinical settings, the rates of MRONJ associated with IV BPs and denosumab were similar, while the sequential treatment of these two drug classes was associated with a much higher risk of MRONJ. © 2022 American Society for Bone and Mineral Research (ASBMR).

Long-term safety of eldecalcitol in Japanese patients with osteoporosis: a retrospective, large-scale database study

INTRODUCTION

This real-world study evaluated whether long-term use of eldecalcitol (ELD) increases the risk of adverse events (AEs), namely, hypercalcemia, acute kidney injury (AKI), and urolithiasis, and analyzed the ELD-induced risk of rare AEs such as osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF).

MATERIALS AND METHODS

Patient records were retrieved from Medical Data Vision (MDV) and Japan Medical Data Center (JMDC) databases. The ELD-treated osteoporosis patient cohort (ELD cohort) was analyzed to determine the incidence rate of the aforementioned AEs. The patient cohort that was prescribed active vitamin D₃ other than ELD (AVD cohort) was analyzed as the reference.

RESULTS

Incidence rates of hypercalcemia, AKI, and urolithiasis in the ELD cohort were 0.942, 0.517, 2.465 events per 100 person-years, respectively, in the MDV dataset, and 0.687, 0.155, 3.785, respectively, in the JMDC dataset. The incidence rates of these AEs in the ELD cohort remained relatively constant throughout ELD treatment. A small number of patients experienced ONJ or AFF during ELD or AVD treatment. The number of ONJ and AFF cases in the both cohorts decreased over time. The two cohorts showed no difference in the concomitant use of anti-bone resorptive agents such as bisphosphonates and denosumab.

CONCLUSION

The risk of hypercalcemia and AKI associated with ELD use observed in this retrospective analysis is similar to that reported previously in the Japanese post-marketing surveillance of ELD. Furthermore, ELD, similar to AVD, may not increase the risk of ONJ and AFF.

Prevalence, Incidence Rate, and Risk Factors of Medication-Related Osteonecrosis of the Jaw in Patients With Osteoporosis and Cancer: A Nationwide Population-Based Study in Japan

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but severe adverse event of antiresorptive agents. However, the precise prevalence and factors associated with the development of MRONJ remain unknown. The present study was performed to describe the prevalence, incidence rate, and risk factors of developing MRONJ.

METHODS

We conducted a population-based retrospective cohort study using the National Database of Health Insurance, an administrative claims database of all patients in Japan. We identified patients who newly began using antiresorptive drugs from April 2015 to December 2018. The primary outcome was the development of MRONJ. We calculated the prevalence and incidence rate of MRONJ and performed a time-dependent Cox proportional hazard regression analysis to examine risk factors for developing MRONJ.

RESULTS

We identified 2,819,310 patients who newly used antiresorptive drugs during the study period. Of these patients, 2,664,104 (94.5%) had osteoporosis and 155,206 had cancer. Among the patients with osteoporosis, 1,603 (0.06%) developed MRONJ; the incidence rate was 22.9 per 100,000 person-years. Among the patients with cancer, 2,274 (1.47%) developed MRONJ; the incidence rate was 1,231.7 per 100,000 person-years. The occurrence of MRONJ was associated with poor oral conditions (including tooth extraction), age, male sex, drug type, concomitant drug use, comorbidities, cancer type, and geographic location.

CONCLUSIONS

The overall prevalence and incidence rate were low, but they were still higher than those in previous studies. Poor oral conditions were more closely related to the development of MRONJ than other factors. These findings suggest that improving poor oral hygiene may be essential to prevent MRONJ.

Assessment of a Claims-Based ICD-9 and ICD-10 Medication-Related Osteonecrosis of the Jaw Algorithm in the United States

PURPOSE

Medication-related osteonecrosis of jaw (MRONJ) is associated with certain drug therapies. Pharmacoepidemiologic studies often rely on electronic healthcare data to assess adverse events following drug exposure. Few studies have developed and validated claims-based MRONJ identification algorithms. This study assessed the performance of claims-based MRONJ algorithms by chart review of potential cases among postmenopausal (PM) women and women with postmenopausal osteoporosis (PMO).

METHODS

Among PM and PMO women sourced from a large US commercial health insurance database affiliated with Optum, potential cases were identified by International Classification of Diseases, 9th and 10th Revisions (ICD-9, ICD-10) diagnosis codes; 200 were selected for chart retrieval, with the goal of obtaining 100 charts in each coding era. Procured charts were redacted and then reviewed by an oral surgeon who determined case status. Positive predictive values (PPV) and 95% confidence intervals (CI) were calculated overall, by cohorts, and coding eras. Baseline characteristics were assessed. Two potential algorithm refinements were explored: using a restricted set of ICD codes; requiring antibiotic use after MRONJ diagnosis.

RESULTS

A total of 1273 potential cases were identified. Of the 200 potential cases selected, 104 (52%) were procured, and six cases were confirmed (PPV 5.8%, 95% CI 2.2, 12.1). Baseline characteristics were largely similar across all strata. Potential algorithm refinements yielded marginal PPV improvement.

CONCLUSION

This study identified a small number of confirmed cases, and the resulting PPVs were low, but consistent with reported studies. Potential algorithm refinements yielded minimal improvements. To our knowledge, this study is the first to report on the identification of MRONJ using ICD-10 codes in the US.

Validity of diagnoses and procedures in Japanese dental claims data

BACKGROUND

Dental claims data have been used for epidemiological studies without establishing the validity of the recorded diagnoses or procedures. The present study aimed to examine the accuracy of diagnoses, procedures, operation time, and the number of teeth recorded in dental claims data.

METHODS

We reviewed the charts of 200 patients who visited and 100 patients who were hospitalized in the Department of General Dentistry, Orthodontics, and Oral and Maxillofacial Surgery in an academic hospital between August 2012 and December 2017. The sensitivity and specificity of the dental claims data for five diseases and 15 procedures were evaluated. We assessed the difference in the number of teeth and duration of general anesthesia between claims data and chart reviews.

RESULTS

Sensitivity was more than 86% for six out of seven diagnoses except for pericoronitis (67%). Specificity ranged from 72% (periodontal disease) to 100% (oral cancer for inpatient). The sensitivity of procedures ranged from 10% (scaling for inpatient) to 100%, and the specificity ranged from 6% (food intake on the day of the surgery) to 100%. The mean (standard deviation [SD]) number of teeth in the chart review was 22.6 (6.8), and in the dental claims was 21.6 (8.6). The mean (SD) operation time was 171.2 (120.3) minutes, while the duration of general anesthesia was 270.9 (171.3) minutes.

CONCLUSIONS

The present study is the first study to validate dental claims data, and indicates the extent of usefulness of each diagnosis and procedure for future dental research using administrative data.

A retrospective study on the incidence of medication-related osteonecrosis of the jaws (MRONJ) associated with different preventive dental care modalities

Purpose

To assess the efficacy of different preventive dental visits and treatments in reducing the risk of medication-related osteonecrosis of the jaws (MRONJ).

Methods

In this retrospective study, patients diagnosed with MRONJ were divided into 5 groups based on available data: no preventive dental visits (group 0); dental visits and compliance with recommended treatments, at the university hospital’s dental clinic (group 1) or maxillofacial surgery unit (group 2), or at a private dentist’s (group 3); dental visits at one of the above and noncompliance with proposed treatments (group 4); patients judged eligible by the oncologist on panoramic radiography (group 5). Patients were classified on severity of MRONJ according to the Italian SIPMO/SICMF 2.0 staging system. A descriptive analysis was performed on the results. Fisher’s exact test was applied (p < 0.05).

Results

Ninety-three patients diagnosed with MRONJ were considered for the study, but 22 were excluded due to a lack of data, leaving a sample of 71 cases. MRONJ staging was only 0 for some patients (26.92%) in group 0. In all groups, the majority of patients had stage 2 MRONJ. The proportions of cases in stage 3 were 7.69% in group 0, 18.18% in group 3, and 43.48% in group 5. Groups 0 and 3 were somewhat similar as regard MRONJ staging. Most patients in group 5 had MRONJ stage 2 or 3. No statistically significant differences emerged between the groups.

Conclusions

Preventive dental care can reduce the risk of MRONJ providing patients comply with the specialist’s recommendations.

Medication-Related Osteonecrosis of the Jaw: A Critical Narrative Review

Background: Nearly two decades have passed since a paradoxical reaction in the orofacial region to some bone modifying agents and other drugs was recognized, namely medication-related osteonecrosis of the jaw (MRONJ). Purpose: The aim of this manuscript was to critically review published data on MRONJ to provide an update on key terminology, concepts, and current trends in terms of prevention and diagnosis. In addition, our objective was to examine and evaluate the therapeutic options available for MRONJ. Methods: The authors perused the most relevant literature relating to MRONJ through a search in textbooks and published articles included in several databases for the years 2003–2021. Results and conclusions: A comprehensive update of the current understanding of these matters was elaborated, addressing these topics and identifying relevant gaps of knowledge. This review describes our updated view of the previous thematic blocks, highlights our current clinical directions, and emphasizes controversial aspects and barriers that may lead to extending the accumulating body of evidence related to this severe treatment sequela.

Lack of evidence in reducing risk of MRONJ after teeth extractions with systemic antibiotics

A systematic review was carried out to identify if periprocedural administration of systemic antibiotics could decrease risk of medication-related osteonecrosis of the jaws (MRONJ) in patients under antiresorptive and/or biologic agents for teeth extraction. PubMed/MEDLINE and Scopus were systematically searched for case-series with more than 10 patients, retrospective/prospective studies, and trials concerning this issue. Manual searching of references from previous reviews was also carried out. Of 1,512 results, 17 studies were included, focusing on antibiotics for extraction in patients under intravenous bisphosphonates (8 studies), oral bisphosphonates (2 studies), oral and intravenous bisphosphonates (6 studies), and denosumab (1 study), of which 12 performed dental extraction with surgical flap. With no trials found, "quality in prognosis studies" (QUIPS) tool was used to evaluate risk of bias. First-line treatment was 2-3 grams of oral amoxicillin in 76.4% of studies; 300-600 mg of clindamycin was the alternative treatment in 23.5% of studies. Treatment ranged from 3 to 20 days, consisting of 6-7 days in 47% of studies. No microbiologic insight was provided. A significantly higher risk of MRONJ for patients unexposed to antibiotics was provided in one retrospective study. QUIPS tool revealed moderate-high risk of bias. With empirical data from bias-carrying, heterogeneous observational studies, the validity of antibiotics is yet to be established.

Is implant surgery a risk factor for osteonecrosis of the jaw in older adult patients with osteoporosis? A national cohort propensity score-matched study

OBJECTIVES

This study aimed to investigate the association between dental implant therapy and osteonecrosis of the jaw (ONJ) in osteoporotic patients and the relationship between tooth extraction, dental implantation, and ONJ.

MATERIAL AND METHODS

This retrospective cohort study used the Customized Health Information Data from the National Health Insurance Corporation in South Korea. The study population included patients older than 70 years with a history of osteoporosis; the cases included patients who had undergone dental implant surgery between July 2014 and July 2016 with specific procedure codes. The case and control cohorts were stratified by tooth extraction because it was the strongest risk factor to consider in this study. Each group of patients was matched using the propensity score. To investigate the relationship between dental implants and ONJ, a Cox proportional hazard model was applied to socio-economic factors, comorbidities, and bisphosphonates (BPs). All analyses were conducted using SAS statistical software.

RESULTS

Based on the fully adjusted model, the propensity score-matched osteoporosis patients with dental implants had a 0.51 times hazard ratio of osteonecrosis. On the contrary, tooth extraction was associated with a higher risk of ONJ (HR = 5.89). The patients with rheumatoid arthritis (RA) and those using BPs had a higher HR, respectively, 6.80 and 4.09 HR (p < .001).

CONCLUSIONS

Dental implantation was not a risk factor and patients with implants show rather lower ratios. However, older osteoporotic Korean patients who had undergone tooth extraction had higher risks of ONJ. A significantly higher risk of ONJ was associated with RA and BPs as well.

Gradual, but Not Sudden, Dose-Dependent Increase of ONJ Risk With Bisphosphonate Exposure: A Nationwide Cohort Study in Women With Osteoporosis

BACKGROUND

A causal relationship of bisphosphonate (BP) exposure with osteonecrosis of the jaw (ONJ) has been reported; however, a definite dose-dependent risk remains to be elucidated beyond current vague recommendations of 4-year oral BP for ONJ risk increase.

OBJECTIVE

To identify the effect of bisphosphonate cumulative dose on ONJ development in women with osteoporosis.

METHODS

A retrospective cohort study was designed using the National Health Insurance Service-National Health Screening database of Korea. Females over the age of 50 were diagnosed with osteoporosis based on the International Classification of Diseases 10th revision (ICD-10) codes (M80, M81, and M82) with bisphosphonate prescriptions. The cumulative dose of bisphosphonate was calculated using defined daily doses (DDD) to provide an accurate BP cumulative effect on ONJ occurrence. Osteonecrosis of the jaw was identified using both ICD-10 codes and related procedure codes. The incidence rates of ONJ and hazard ratios were estimated according to the bisphosphonate cumulative dose.

RESULTS

Among 74,491 included subjects, 190 cases of ONJ were identified. The incidence rate substantially increased after BP cumulative dose over 1 year (25.75 for DDD < 365, which increased to 53.43 for 365 ≤ DDD < 730). Compared to subjects with a cumulative dose of DDD < 365, subjects with a cumulative dose of 365 ≤ DDD < 730 had 2.36-fold hazard for developing ONJ (p < 0.001).

CONCLUSION

A bisphosphonate cumulative dose of more than 1 year had an increased risk of ONJ development. A gradual, but not sudden, dose-dependent increase in ONJ risk with BP exposure needs to be considered in providing the optimal BP treatment duration.

SAPHO Syndrome Involving the Mandible Treated With 99Tc-MDP

SAPHO (synovitis-acne-pustulosis-hyperostosis-osteitis) syndrome is a chronic inflammatory disease involving multiple organs such as skin and bones. At present, its etiology and pathogenesis are still unclear. Due to the variety of clinical manifestations and the small number of SAPHO syndrome involving the mandible, accurate diagnosis is difficult for oral and maxillofacial surgeons. Here, the authors report that a male patient with SAPHO syndrome involving the maxillofacial skin and mandible, followed for 3 years. We used Tc-MDP (technetium-99 conjugated with methylene disphosphonate) (commercially known as Yunke) to treat this disease and achieved significant clinical treatment. This suggests that Tc-MDP can be used as a bisphosphonate to treat SAPHO syndrome.

Clinical effect of early bisphosphonate treatment for pyogenic vertebral osteomyelitis with osteoporosis: An analysis by the Cox proportional hazard model

BACKGROUND CONTEXT

Patients with pyogenic vertebral osteomyelitis (PVO) are expected to have an increased risk of bone loss. Therefore, early bisphosphonate therapy would be clinically effective for PVO patients with osteoporosis.

PURPOSE

This study aimed to investigate the effect of bisphosphonate on clinical outcomes of PVO patients with osteoporosis.

STUDY DESIGN/SETTING

A retrospective comparative study.

PATIENT SAMPLE

PVO patients with osteoporosis.

OUTCOME MEASURES

Four events of interest for Cox proportional hazard model included surgical treatment, recurrence of infection, subsequent fracture of adjacent vertebral bodies, and death.

METHODS

PVO patients were divided into three groups: group A (initiation of bisphosphonate within 6 weeks after PVO diagnosis), group B (initiation of bisphosphonate between 6 weeks and 3 months after PVO diagnosis), and group C (no treatment for osteoporosis). Cox proportional hazard model was used for the four events of interest.

RESULTS

A total of 360 PVO patients with osteoporosis were investigated for the four events of interest. Group A had significantly lower hazard ratios for undergoing later (>6 weeks after diagnosis) surgery than group C (p = .014) despite similar occurrences of overall surgery. A significant difference was also observed in the occurrence of subsequent fractures at adjacent vertebral bodies (p = .001 for model 1 and p = .002 for model 2). Groups A and B had significantly lower hazard ratios for subsequent fracture than group C. No significant differences were observed in the hazard ratios of recurrence and death among the three groups.

CONCLUSIONS

Early bisphosphonate treatment in PVO patients with osteoporosis was associated with a significantly lower occurrence of subsequent vertebral fracture at adjacent vertebral bodies and lower occurrence of subsequent surgery.

Poria cocos polysaccharide attenuates RANKL-induced osteoclastogenesis by suppressing NFATc1 activity and phosphorylation of ERK and STAT3

Pathological fractures caused by osteolytic lesions seriously threaten the health of patients. Osteoclasts play important roles in bone resorption whose hyperfunction are closely related to osteolytic lesions. Studies on osteoclast differentiation and function assist in the prevention of excessive bone loss associated diseases. We screened a variety of natural compounds with anti-inflammatory effect and found that poria cocos polysaccharide (PCP) inhibited RANKL-induced osteoclast formation and bone resorption via TRAcP staining, immunofluorescence, RT-PCR and western blot. PCP down-regulated phosphorylation of STAT3, P38, ERK and JNK, and thus repressed the expression of NFAcT1 and c-Fos during RANKL-induced osteoclastogenesis. Besides, the expression of bone resorption related genes such as TRAcP and CTSK was suppressed by PCP. The results suggest that PCP can be invoked as a candidate for the treatment of osteolytic diseases by inhibiting osteoclastogenesis.