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Suryani IR, Shujaat S, That MT, Coucke W, Jacobs R. Prediction of wound healing status following dental extraction using Adapted-University of Connecticut osteonecrosis numerical scale: A retrospective study. Health Sci Rep 2024; 7:e2184. [PMID: 38915354 PMCID: PMC11194833 DOI: 10.1002/hsr2.2184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/06/2024] [Accepted: 05/22/2024] [Indexed: 06/26/2024] Open
Abstract
Background and Aims There is a scarcity of evidence concerning the use of a prognostic instrument for predicting normal healing, delayed healing, and medication-related osteonecrosis of the jaw (MRONJ) occurrence following tooth extraction in medically compromised patients. The present study aimed to predict healing outcomes following tooth extraction in medically compromised patients using an Adapted-University of Connecticut osteonecrosis numerical scale (A-UCONNS). Methods The digital medical records of medically compromised patients were reviewed, who underwent tooth extraction. The A-UCONNS parameters included the initial pathological condition, dental procedures, comorbidities (smoking habits, type and duration of medication, and type of intervention), and administered antiresorptive (AR) medications. Each parameter was assigned a different weight, and the scores were then accumulated and classified into three categories: minimal risk (less than 10), moderate risk (10-15), and significant risk (16 or more). The patient's healing status was categorized as normal healing, delayed healing, or MRONJ. Results A total of 353 male patients (mean age: 67.4 years) were recruited from a pool of 3977 patients, where 12.46% of patients had delayed wound healing, and 18.69% developed MRONJ. The median A-UCONNS scores for MRONJ were higher based on initial pathology, comorbidity, and AR drugs compared to normal or delayed healing. In addition, a significant relationship existed between A-UCONNS and healing outcomes (p < 0.05), with a unit increase in A-UCONNS associated with 1.347 times higher odds of experiencing MRONJ compared to normal healing. In contrast, a low score was linked to an increased likelihood of normal wound healing. Conclusion The A-UCONNS could act as a promising tool for predicting wound healing outcomes. It can provide clinicians the ability to pinpoint patients at high risk and allow tailoring of patient-specific strategies for improving healing outcomes following tooth extraction.
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Affiliation(s)
- Isti R. Suryani
- Department of Imaging & Pathology, OMFS IMPATH Research Group, Faculty of Medicine, KU Leuven & Oral and Maxillofacial SurgeryUniversity Hospitals LeuvenLeuvenBelgium
- Department of Dentomaxillofacial Radiology, Faculty of DentistryUniversitas Gadjah MadaYogyakartaIndonesia
| | - Sohaib Shujaat
- Department of Imaging & Pathology, OMFS IMPATH Research Group, Faculty of Medicine, KU Leuven & Oral and Maxillofacial SurgeryUniversity Hospitals LeuvenLeuvenBelgium
- King Abdullah International Medical Research Center, Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Saud bin Abdulaziz University for Health SciencesMinistry of National Guard Health AffairsRiyadhSaudi Arabia
| | - Minh T. That
- Department of Imaging & Pathology, OMFS IMPATH Research Group, Faculty of Medicine, KU Leuven & Oral and Maxillofacial SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Reinhilde Jacobs
- Department of Imaging & Pathology, OMFS IMPATH Research Group, Faculty of Medicine, KU Leuven & Oral and Maxillofacial SurgeryUniversity Hospitals LeuvenLeuvenBelgium
- Department of Dental MedicineKarolinska InstitutetStockholmSweden
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Konarski W, Poboży T, Konarska K, Śliwczyński A, Kotela I, Krakowiak J. Exploring the Impact of Novel Anti-Cancer Therapies on Jaw Osteonecrosis and Other Bones: A Comprehensive Review. J Clin Med 2024; 13:1889. [PMID: 38610654 PMCID: PMC11012550 DOI: 10.3390/jcm13071889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Osteonecrosis is a debilitating condition characterized by the loss of blood supply to the bones, leading to bone death. This condition can impact various bones, including the jaw, which significantly affects patients' quality of life by causing difficulties in swallowing, feeding, chewing, and speaking, along with swollen, painful mucous membranes and chronic sinusitis. Osteonecrosis can arise due to treatment with antiresorptive drugs. However, there is a growing number of reports of osteonecrosis following novel targeted anti-cancer treatments, such as tyrosine kinase inhibitors (TKIs) and biological therapies. The pathogenesis of osteonecrosis is linked to the side effects of the antiangiogenic mechanisms of these medications, leading to a disrupted blood flow. Our review aims to examine recent insights into osteonecrosis triggered by new anti-cancer drugs. Most reports focus on the osteonecrosis of the jaw (ONJ); however, we discovered that some authors have described cases of osteonecrosis affecting the femoral head or elbow following novel anti-cancer treatments. Prevention is a key component in managing osteonecrosis. Therefore, a comprehensive risk assessment should always be performed before and during anti-cancer therapy.
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Affiliation(s)
- Wojciech Konarski
- Department of Orthopaedic Surgery, Ciechanów Hospital, 06-400 Ciechanów, Poland;
| | - Tomasz Poboży
- Department of Orthopaedic Surgery, Ciechanów Hospital, 06-400 Ciechanów, Poland;
| | - Klaudia Konarska
- Medical Rehabilitation Center, Sobieskiego 47D, 05-120 Legionowo, Poland;
| | - Andrzej Śliwczyński
- Social Medicine, Department of Social and Preventive Medicine, Medical University of Lodz, 90-647 Lodz, Poland; (A.Ś.); (J.K.)
| | - Ireneusz Kotela
- Department of Orthopedic Surgery and Traumatology, Central Research Hospital of Ministry of Interior, Wołoska 137, 02-507 Warsaw, Poland;
| | - Jan Krakowiak
- Social Medicine, Department of Social and Preventive Medicine, Medical University of Lodz, 90-647 Lodz, Poland; (A.Ś.); (J.K.)
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Dipalma G, Inchingolo AM, Malcangi G, Ferrara I, Viapiano F, Netti A, Patano A, Isacco CG, Inchingolo AD, Inchingolo F. Sixty-Month Follow Up of Clinical MRONJ Cases Treated with CGF and Piezosurgery. Bioengineering (Basel) 2023; 10:863. [PMID: 37508890 PMCID: PMC10376556 DOI: 10.3390/bioengineering10070863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
AIMS Medication-related osteonecrosis of the jaw (MRONJ) is a drug-related adverse reaction characterized by bone destruction and necrosis in the jaw. This case series aims to evaluate the treatment approaches and outcomes in MRONJ patients. MATERIALS AND METHODS The retrospective study was conducted at the Dental Unit of the University of Bari, Italy. Patients with MRONJ were treated and followed up for 60 months. The treatment approach involved piezosurgery and concentrated growth factor (CGF). Six clinical cases from this group are described in detail. RESULTS None of the patients showed recurrence of necrotic MRONJ lesions during the follow-up period. The surgical interventions, including bone resections and the application of CGF, resulted in successful mucosal healing and the prevention of disease progression. CONCLUSIONS This study highlights the complexity of managing MRONJ and the importance of a multidisciplinary approach. Conservative treatment options and minimally invasive surgery have shown efficacy in controlling symptoms and improving patients' quality of life. However, the optimal treatment approach remains a challenge, and further studies are needed to evaluate alternative therapies and resective surgery. A comprehensive preoperative evaluation and collaboration among dental, endocrinology, and oncology specialists are crucial for personalized and multidisciplinary management. Ongoing research efforts are necessary to explore new therapeutic modalities and improve our understanding of MRONJ management, providing better support to patients dealing with this complex condition.
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Affiliation(s)
- Gianna Dipalma
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Angelo Michele Inchingolo
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Giuseppina Malcangi
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Irene Ferrara
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Fabio Viapiano
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Anna Netti
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Assunta Patano
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Ciro Gargiulo Isacco
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Alessio Danilo Inchingolo
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Francesco Inchingolo
- Department of Interdisciplinary Medicine, School of Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
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Ristow O, Schnug G, Smielowksi M, Moratin J, Pilz M, Engel M, Freudlsperger C, Hoffmann J, Rückschloß T. Diagnostic accuracy comparing OPT and CBCT in the detection of non-vital bone changes before tooth extractions in patients with antiresorptive intake. Oral Dis 2023; 29:1039-1049. [PMID: 34637576 DOI: 10.1111/odi.14048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/13/2021] [Accepted: 10/07/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To compare the diagnostic accuracy in detecting early non-vital bone changes between orthopantomography (OPT) and cone-beam computed tomography (CBCT) in correlation with histopathological findings before tooth extractions in patients with antiresorptive (AR) intake. SUBJECTS Patients with an indication tooth extraction who had received OPT and CBCT preoperatively while or after undergoing AR treatment were prospectively enrolled over a 24-month period in the progesterone in spontaneous miscarriage (PRISM) trial. Imaging studies were randomly analyzed by three examiners for early non-vital bone changes using specific predefined characteristics and a 5-level scale (1 definite absence of criteria to 5 definite presence of criteria). Sensitivity and specificity values were calculated in correlation with the histopathologically evaluated bone samples at the time point of tooth extraction. RESULTS One hundred thirty patients with 237 treated extraction sites met the inclusion criteria. For all images evaluated by all examiners, CBCT (430/492; 87.4%; receiver operating characteristic [ROC]: area under the curve [AUC] = 0.88; p < 0.001) was more likely to detect histopathologically confirmed non-vital bone than the OPT (132/492; 26.8%; ROC: AUC = 0.562; p = 0.115). CONCLUSIONS In the detection of non-vital bone changes, CBCT is superior to OPT in both sensitivity and specificity. Specific imaging characteristics allow for the prediction of early non-vital bone changes already at the time before tooth extractions.
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Affiliation(s)
- Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Schnug
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Smielowksi
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julius Moratin
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Pilz
- Institute of Medical Biometry and Informatics, Department of Biometry, University of Heidelberg, Heidelberg, Germany
| | - Michael Engel
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Rückschloß
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
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5
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Hussain M, Khan F, Al Hadidi S. The use of bone-modifying agents in multiple myeloma. Blood Rev 2023; 57:100999. [PMID: 36050125 DOI: 10.1016/j.blre.2022.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 01/28/2023]
Abstract
Multiple myeloma is a hematological neoplasm characterized by abnormal proliferation of plasma cells in the bone marrow and is usually associated with increased bone pain and skeletal-related events such as pathological fracture and/or spinal cord compression. Myeloma bone disease results in changes in the bone-marrow microenvironment evidenced by increased osteoclastic activity and/or decreased osteoblastic activity, which negatively affect quality of life. Treatment of myeloma bone disease includes bisphosphonates or denosumab (bone-modifying agents). These agents do not induce the formation of new bone or repair existing bone damage, but they can decrease bone pain and the risk of pathological fracture. While these agents improve quality of life, it is not known whether they improve overall survival. This review focuses on different classes of bone-modifying agents, their mechanisms of action, time of initiation, duration of therapy, and potential survival benefits.
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Affiliation(s)
- Munawwar Hussain
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Fatima Khan
- Department of Hematology Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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Okawa H, Kondo T, Hokugo A, Cherian P, Campagna JJ, Lentini NA, Sung EC, Chiang S, Lin YL, Ebetino FH, John V, Sun S, McKenna CE, Nishimura I. Mechanism of bisphosphonate-related osteonecrosis of the jaw (BRONJ) revealed by targeted removal of legacy bisphosphonate from jawbone using competing inert hydroxymethylene diphosphonate. eLife 2022; 11:e76207. [PMID: 36017995 PMCID: PMC9489207 DOI: 10.7554/elife.76207] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) presents as a morbid jawbone lesion in patients exposed to a nitrogen-containing bisphosphonate (N-BP). Although it is rare, BRONJ has caused apprehension among patients and healthcare providers and decreased acceptance of this antiresorptive drug class to treat osteoporosis and metastatic osteolysis. We report here a novel method to elucidate the pathological mechanism of BRONJ by the selective removal of legacy N-BP from the jawbone using an intra-oral application of hydroxymethylene diphosphonate (HMDP) formulated in liposome-based deformable nanoscale vesicles (DNV). After maxillary tooth extraction, zoledronate-treated mice developed delayed gingival wound closure, delayed tooth extraction socket healing and increased jawbone osteonecrosis consistent with human BRONJ lesions. Single cell RNA sequencing of mouse gingival cells revealed oral barrier immune dysregulation and unresolved proinflammatory reaction. HMDP-DNV topical applications to nascent mouse BRONJ lesions resulted in accelerated gingival wound closure and bone socket healing as well as attenuation of osteonecrosis development. The gingival single cell RNA sequencing demonstrated resolution of chronic inflammation by increased anti-inflammatory signature gene expression of lymphocytes and myeloid-derived suppressor cells. This study suggests that BRONJ pathology is related to N-BP levels in jawbones and demonstrates the potential of HMDP-DNV as an effective BRONJ therapy.
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Affiliation(s)
- Hiroko Okawa
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
- Division of Molecular & Regenerative Prosthodontics, Tohoku University Graduate School of DentistrySendaiJapan
| | - Takeru Kondo
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
- Division of Molecular & Regenerative Prosthodontics, Tohoku University Graduate School of DentistrySendaiJapan
| | - Akishige Hokugo
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
- Regenerative Bioengineering and Repair Laboratory, Division of Plastic and Reconstructive Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los AngelesLos AngelesUnited States
| | | | - Jesus J Campagna
- Department of Neurology, David Geffen School of Medicine at University of California, Los AngelesLos AngelesUnited States
| | - Nicholas A Lentini
- Department of Chemistry, University of Southern CaliforniaLos AngelesUnited States
| | - Eric C Sung
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
| | - Samantha Chiang
- Division of Oral & Systemic Health Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
| | - Yi-Ling Lin
- Section of Oral & Maxillofacial Pathology, University of California, Los Angeles School of DentistryLos AngelesUnited States
| | | | - Varghese John
- Department of Neurology, David Geffen School of Medicine at University of California, Los AngelesLos AngelesUnited States
| | - Shuting Sun
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
- BioVinc, LLCPasadenaUnited States
| | - Charles E McKenna
- Department of Chemistry, University of Southern CaliforniaLos AngelesUnited States
| | - Ichiro Nishimura
- Weintraub Center for Reconstructive Biotechnology, Division of Regenerative & Reconstructive Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
- Division of Oral & Systemic Health Sciences, University of California, Los Angeles School of DentistryLos AngelesUnited States
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7
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Migliorati CA. Oral Complications in Cancer Patients–Medication-Related Osteonecrosis of the Jaw (MRONJ). FRONTIERS IN ORAL HEALTH 2022; 3:866871. [PMID: 35558547 PMCID: PMC9086704 DOI: 10.3389/froh.2022.866871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/18/2022] [Indexed: 12/22/2022] Open
Abstract
Medication-Related Osteonecrosis of the Jaw (MRONJ) was first reported in 2003. Despite the progress in the understanding of this oral complication in cancer patients for the past 18 years, there is still discussion about the best way to define MRONJ, prevent the complication, how to diagnose, and the options of treatment available. The initial reports associated MRONJ to bisphosphonates and denosumab, medications that work as bone-modifying agents. Later, other agents such as the antiangiogenics, have also been reported to cause the oral complication, either alone or in combination with antiresorptives. Initially, these medications were prescribed to patients with osteoporosis and cancers patients with bone metastasis. Today, because of the effect of the medications in the bone remodeling system, patients with several other diseases such as giant cell tumors, rheumatoid arthritis, Paget's disease of bone, fibrous dysplasia, osteogenesis imperfecta, are managed with these medications, significantly increasing the population of individuals at risk for developing MRONJ. This mini review focused on the cancer patient. It updates the dental clinician on the recent scientific literature about MRONJ and provides information on how to diagnose and manage patients being treated with these medications, suggests protocols to prevent the development of MRONJ, and present ways to manage those patients who develop the oral complication.
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Anastasilakis AD, Pepe J, Napoli N, Palermo A, Magopoulos C, Khan AA, Zillikens MC, Body JJ. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab 2022; 107:1441-1460. [PMID: 34922381 PMCID: PMC9016445 DOI: 10.1210/clinem/dgab888] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ). OBJECTIVE We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them. METHODS A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM. RESULTS The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. CONCLUSION The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.
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Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 General Military Hospital, 564 29 N Efkarpia Thessaloniki, Greece
- Correspondence: Athanasios D. Anastasilakis, PhD, Department of Endocrinology, 424 General Military Hospital, Ring Rd, 564 29 N Efkarpia, Thessaloniki, Greece.
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Christos Magopoulos
- Department of Oral and Maxillofacial Surgery, 424 General Military Hospital, 56429 Thessaloniki, Greece
| | - Aliya A Khan
- Division of Endocrinology and Metabolism and Geriatrics, McMaster University, L8N3Z5 Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, 2040 Rotterdam, the Netherlands
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, 1050 Brussels, Belgium
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Patel V, Patel S, Grossman S, Wali R, Burns M, Zebic L, Enting D, Henien M. The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 4: miscellaneous cancers. Br Dent J 2022; 232:213-218. [PMID: 35217738 DOI: 10.1038/s41415-022-3983-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022]
Abstract
This article discusses relevant information for the dental sector regarding metastatic cancers beyond breast and prostate cancer. Typically, tumour sites such as lung, renal, colorectal, gastrointestinal, thyroid, hepatic and pancreatic cancers are increasingly being referred for bone-targeting agents upon evidence of bone metastases.The current article explores the presenting dental status of these tumour groups on the background of survival outcomes. In addition, the article provides insight towards the complexity in achieving 'dental fitness' and whether 'dental stability' could be an alternative to consider via palliative dentistry in certain cases.
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Affiliation(s)
- Vinod Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK.
| | - Sheelen Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | | | - Rana Wali
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Megan Burns
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Lara Zebic
- Oral Surgery Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Deborah Enting
- Medical Oncology, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Marianne Henien
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
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10
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Patel V, Burns M, Patel S, Grossman S, Wali R, Sassoon I, Pintus E, Henien M. The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 3: prostate cancer. Br Dent J 2022:10.1038/s41415-022-3928-0. [PMID: 35145242 DOI: 10.1038/s41415-022-3928-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022]
Abstract
Introduction Metastatic prostate cancer (MPC) patients due to receive bone-targeting agents (BTAs) are expected to undertake a dental assessment before commencing. The aim of this study was to determine the dental status of this tumour group and understand the challenges the dental practitioner faces in attempting to achieve 'dental fitness'.Materials and methods Data were retrospectively collected from a dedicated pre-BTA dental assessment clinic and analysed for MPC. Statistical analysis and observational data were used to compare patient and tumour demographics.Results A total of 111 patients were included in this cohort, with the majority of patients presenting with only bone metastases (BM) and no additional metastatic sites. On average, MPC patients presented with 19.3 teeth and were below the threshold for functional dentition. The 75-84-year-old age group had the worst horizontal bone loss score and subsequently lose six teeth over a decade (p = 0.001). In addition, all MPC tumour sub-categories showed favourable survival rates.Conclusion MPC patients have a high dental burden on presentation, likely associated with their age. Favourable survival prospects and the cumulation of BTAs and dental disease would suggest a heightened risk of medication-related osteonecrosis of the jaw in this group compared to many other tumour sites.
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Affiliation(s)
- Vinod Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK.
| | - Megan Burns
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Sheelen Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | | | - Rana Wali
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Isabel Sassoon
- Computer Science Department, Brunel University, London, Kingston Lane, Uxbridge, UB8 3PH, UK
| | - Elias Pintus
- Medical Oncology, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Marianne Henien
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
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11
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Singh A, Pischek A, Randazzo JR, Huryn JM, Estilo CL, Preeshagul I, Yom SK. Ramucirumab-related osteonecrosis of the jaw. Oral Oncol 2022; 125:105660. [PMID: 34954503 PMCID: PMC10324387 DOI: 10.1016/j.oraloncology.2021.105660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Annu Singh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
| | - Andrew Pischek
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States
| | - Joseph R Randazzo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
| | - Joseph M Huryn
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
| | - Cherry L Estilo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
| | - Isabel Preeshagul
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
| | - SaeHee K Yom
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States.
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12
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Patel V, Grossman S, Wali R, Burns M, Patel S, Sassoon I, Rudman S, Henien M. The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 1: an overview. Br Dent J 2022:10.1038/s41415-021-3825-y. [PMID: 35027687 DOI: 10.1038/s41415-021-3825-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Introduction Dental pre-assessment before bone-targeting agents (BTA) in oncology patients is a well-recognised practice; yet, guidance on this has typically been unable to differentiate between the intricacies of varying oncology groups. This study assesses the presenting dental status of oncology patients with bone metastases (BM) due to commence BTA, to determine whether differences exist with varying tumour groups.Materials and methods Data were retrospectively collected from a dedicated pre-BTA dental assessment clinic. Statistical analysis and observational data were used to compare patient and tumour demographics as well as to their peers via the Adult Dental Health Survey.Results A total of 492 patients with a solid tumour diagnosis and BM requiring BTA were included in this retrospective study. Demographics such as sex, age, smoking status and tumour site were all significant for the number of teeth present (p = 0.000). Furthermore, survival data post-BTA identified prostate, breast and thyroid groups surviving over 12 months following dental assessment (p <0.000). In contrast, the remaining groups such as lung, colorectal and gastrointestinal had poorer outcomes (p <0.000).Conclusion Pre-BTA dental assessment should consider and incorporate additional patient and tumour demographics to allow for a tailored and personalised dental treatment plan. Application of this principle would look to optimise oral function while considering tumour prognosis to avoid over- or under-prescribing pre-BTA dental treatment.
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Affiliation(s)
- Vinod Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK.
| | | | - Rana Wali
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Megan Burns
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Sheelen Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Isabel Sassoon
- Computer Science Department, Brunel University, London, Kingston Lane, Uxbridge, UB8 3PH, UK
| | - Sarah Rudman
- Medical Oncology, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Marianne Henien
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
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Suryani IR, Ahmadzai I, Shujaat S, Ma H, Jacobs R. Non-antiresorptive drugs associated with the development of medication-related osteonecrosis of the jaw: a systematic review and meta-analysis. Clin Oral Investig 2022; 26:2269-2279. [PMID: 35013781 DOI: 10.1007/s00784-021-04331-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim of this systematic review was to provide evidence related to the association between non-antiresorptive medications and MRONJ. MATERIALS AND METHODS The following three electronic databases were screened: PubMed, EMBASE, and Web of Science from December 2020 until April 2021. Two reviewers independently performed the study selection, data extraction, and quality assessment of the included studies. The Newcastle-Ottawa Scale (NOS) was used for assessing the risk of bias. A meta-analysis was performed for assessing the relationship between MRONJ and non-antiresorptive medications. RESULTS The search strategy retrieved 996 articles. Following removal of duplicates, title, and abstract screening and full-text reading, 58 publications were eligible to be included in the review. A total of 867 cases of MRONJ were included (33% female, 55% male, 12% no gender reported). The mean age of the patients when MRONJ was diagnosed was 61 years (range 19-100 years) and the average time of diagnosis was 10 months following non-antiresorptive drug therapy. Patients with a history of corticosteroids (0.61, 95% CI 0.39, 0.82, p = < 0.001) and chemotherapy (0.59, 95% CI 0.51, 0.67, p = < 0.001) showed the highest significant effect size (ED) compared to the control group for MRONJ occurrence. CONCLUSION A significant association existed between MRONJ and non-antiresorptive drugs. However, considering limited evidence, findings should be interpreted with caution. CLINICAL RELEVANCE The non-antiresorptive drugs might allow the dentist to apply the principle of "drug holiday" following concurrence from the drug prescribing clinician. PROSPERO REGISTRATION NUMBER CRD42020173891.
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Affiliation(s)
- Isti Rahayu Suryani
- OMFS-IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven and Department of Oral and Maxillofacial Surgery, Campus Sint Rafaël, University Hospitals Leuven, Leuven, Belgium. .,Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Iraj Ahmadzai
- OMFS-IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven and Department of Oral and Maxillofacial Surgery, Campus Sint Rafaël, University Hospitals Leuven, Leuven, Belgium
| | - Sohaib Shujaat
- OMFS-IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven and Department of Oral and Maxillofacial Surgery, Campus Sint Rafaël, University Hospitals Leuven, Leuven, Belgium
| | - Hongyang Ma
- OMFS-IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven and Department of Oral and Maxillofacial Surgery, Campus Sint Rafaël, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven and Department of Oral and Maxillofacial Surgery, Campus Sint Rafaël, University Hospitals Leuven, Leuven, Belgium.,Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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14
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Wu BW, Lee KC, Halepas S, Karlis V. Outcomes of Clinical Trials on Osteonecrosis of the Jaw. Cureus 2021; 13:e17984. [PMID: 34660159 PMCID: PMC8516017 DOI: 10.7759/cureus.17984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/14/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: The purpose of this study was to provide a cross-sectional view of all registered clinical trials enrolling patients with osteonecrosis of the jaw (ONJ). The primary aim was to report predictors of trial completion and publication of results. Materials and Methods: This is a cross-sectional study of ONJ trials registered with ClinicalTrials.gov. For each included entry, trial characteristics and endpoints were recorded. Predictors were enrollment size, etiology, study type, intervention type, sponsor, funding, study locations, number of centers, and specialty of the principal investigator. Outcomes were trial status, publication on PubMed, journal of publication, and length of time between endpoints. Associations between predictors and outcomes were evaluated using chi-square tests and t-tests. Results: The final sample included 26 trials. Overall, 50% of trials were completed and 69% of completed trials were published. Three out of four terminated trials were suspended due to lack of funding. The median enrollment for completed trials was 149 participants with a mean length of five years. All trials included medication-related osteonecrosis of the jaw (MRONJ) patients and 26% also included osteoradionecrosis of the jaw (ORNJ) patients. The majority of trials were observational (65%), conducted internationally (62%), and involved multiple centers (54%). Published trials had a mean time of 5.9 years between trial start and publication, which was comparable to trial length (p=0.90) and appeared in either dental (44%) or cancer (56%) journals. Completion and publication rates were not significantly increased by industry sponsorship/funding, larger enrollment sizes, or multi-center involvement. Oral and maxillofacial surgery was the most represented dental specialty of principal investigators (56%). Conclusions: The majority of completed ONJ trials had their results published in a timely manner. Evidence-based investigation of ONJ is a multi-disciplinary and international effort. Among all specialists, oral and maxillofacial surgeons led the most ONJ trials.
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Affiliation(s)
- Brendan W Wu
- Oral and Maxillofacial Surgery, New York University Langone Health, New York, USA
| | - Kevin C Lee
- Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, USA
| | - Steven Halepas
- Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, USA
| | - Vasiliki Karlis
- Oral and Maxillofacial Surgery, New York University Langone Health, New York, USA.,Oral and Maxillofacial Surgery, NYC Health + Hospitals/Bellevue, New York, USA
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15
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Garzino Demo P, Bojino A, Roccia F, Malandrino MC, Cocis S, Ramieri G. Different Presentation and Outcomes in the Surgical Treatment of Advanced MRONJ in Oncological and Nononcological Patients Taking or Not Corticosteroid Therapy. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7855497. [PMID: 38523862 PMCID: PMC10960651 DOI: 10.1155/2021/7855497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/02/2021] [Indexed: 03/26/2024]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect caused by antiangiogenic antiresorptive drugs used to treat various oncological and non oncological diseases. The clinical and radiological characteristics of MRONJ depend on the type of causative drug, the time of administration, and its dosage. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases (e.g., high doses of methotrexate up to 30 mg daily) significantly increase the chances of acquiring MRONJ. The risk factors themselves can affect treatment outcomes. Although the main scientific societies have recently disseminated good practice rules on the patient's prevention, diagnosis, and management, there are still no guidelines on shared therapeutic strategies. In general, if conservative treatment fails, surgical treatment is considered, including local debridement, osteoplasty, and marginal or segmental osteotomy. In literature, cohorts of heterogeneous patients with MRONJ have been analyzed for a long time, resulting in a lack of uniformity of information and difficulties interpreting the data. According to the American Association of Oral and Maxillofacial Surgeons criteria, this retrospective study evaluates the surgical treatment outcomes of 64 patients with stage II-III MRONJ, evaluated at the Department of Maxillofacial Surgery of the University of Turin (Italy). The first objective of this retrospective study is to evaluate treatment results for stages II-III in all cases; the second objective is to evaluate the same results by dividing the sample into different cohorts of patients: first, based on the underlying pathology, i.e., oncological and non oncological, and secondly, based on the drug or combination of drugs they took.
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Affiliation(s)
- Paolo Garzino Demo
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
| | - Alessandro Bojino
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
| | - Fabio Roccia
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
| | - Maria Chiara Malandrino
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
| | - Stefan Cocis
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
| | - Guglielmo Ramieri
- Division of Maxillofacial Surgery, Surgical Science Department, Città della Salute e delle Scienze Hospital, University of Turin, Italy
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The Treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Systematic Review with a Pooled Analysis of Only Surgery versus Combined Protocols. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168432. [PMID: 34444181 PMCID: PMC8392050 DOI: 10.3390/ijerph18168432] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 01/03/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction of antiresorptive and antiangiogenic agents, and it is also a potentially painful and debilitating condition. To date, no specific studies have prospectively evaluated the efficacy of its treatment and no robust standard of care has been established. Therefore, a systematic review (2007–2020) with a pooled analysis was performed in order to compare MRONJ surgical techniques (conservative or aggressive) versus combined surgical procedures (surgery plus a non-invasive procedure), where 1137 patients were included in the pooled analysis. A statistically significant difference in the 6-month improvement rate, comparing combined conservative surgery versus only aggressive (91% versus 72%, p = 0.05), was observed. No significant difference regarding any group with respect to the 6-month total resolution rate (82% versus 72%) was demonstrated. Of note, conservative surgery combined with various, adjuvant, non-invasive procedures (ozone, LLLT or blood component + Nd:YAG) was found to achieve partial or full healing in all stages, with improved results and the amelioration of many variables. In conclusion, specific adjuvant treatments associated with minimally conservative surgery can be considered effective and safe in the treatment of MRONJ, although well-controlled studies are a requisite in arriving at definitive statements
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Abstract
ABSTRACT Patient was a 73-year-old woman with metastatic renal cell carcinoma. Bone scan showed multifocal bone metastases. The patient received cabozantinib treatment for more than 1 year. On the follow-up bone scan, the previously biopsy-proven left pelvic bone lesion has improved, whereas the right maxillary lesion showed increased extent and intensity of abnormal radiotracer uptake. Given the different change pattern of these lesions, the right maxillary lesion was further evaluated. Biopsy results confirmed devitalized bone with bacterial colonies overgrowth and without tumor cell, suggestive of medication-related osteonecrosis.
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Affiliation(s)
- Guofan Xu
- From the Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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18
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Choosing the Right Partner for Medication Related Osteonecrosis of the Jaw: What Central European Dentists Know. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094466. [PMID: 33922326 PMCID: PMC8122803 DOI: 10.3390/ijerph18094466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a side effect of antiresorptive drugs. In this online survey, the awareness and knowledge of dentists regarding MRONJ was evaluated, and potential implications for oncologists are discussed. Questionnaires were emailed to dentists from Germany, Austria, Switzerland, and South Tyrol to evaluate disease-related knowledge and management. In addition to the overall score, a separate score was calculated for knowledge (maximum score: 15 points) and management (maximum score: 6 points) questions, and 1197 valid replies with completed questionnaires were received. The mean overall score was 10.45 ± 3.97 points, the mean knowledge score was 7.68 ± 3.05 points, and the mean management score was 2.76 ± 1.77 points. Factors influencing the outcome of the overall score were age, specialization, continuous professional education, and the number of dental screening exams in patients before antiresorptive therapy. Due to the considerable lack of knowledge regarding MRONJ among dentists, MRONJ patients and subjects at risk should be guided towards specialists for dental screening, treatment, and follow-up. This is important from an oncologic point of view to avoid any delay for treatment start of antiresorptives, and to reveal a potentially emerging osteonecrosis at an early stage, thus, avoiding the need for interruption or even cancellation of antiresorptive therapy.
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Topaloglu Yasan G, Adiloglu S, Koseoglu OT. Retrospective evaluation of pathologic fractures in medication related osteonecrosis of the jaw. J Craniomaxillofac Surg 2021; 49:518-525. [PMID: 33933324 DOI: 10.1016/j.jcms.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/25/2021] [Accepted: 03/20/2021] [Indexed: 10/21/2022] Open
Abstract
The aim of this study was to focus on the MRONJ-related pathologic fractures, their incidence, and to analyze possible causative factors for their occurrence. Pathologic fracture in patients suffering frm MRONJ were identified, examined in detail, and the patient characteristics were evaluated. In 116 patients (73 female and 43 male; mean age 62.08 ± 13.6 years), pathologic fracture incidence was found to be 4.31%. Zoledronic acid was the most commonly used anti-resorptive drug (77.8%). Median antiresorptive usage was 24 months. Five patients had pathologic fractures in the mandible. Four fracture patients had metastatic prostate cancer, and one had metastatic renal cell cancer. This case series study can provide clinical insight into which factors are associated with pathologic fractures. Cancer type, medical comorbidities, additive toxicity of the combination of antiresorptive and antiangiogenic drugs, specific pathogens, and dento-alveolar surgical procedures may be some of the important factors that need to be considered. Since MRONJ-related pathologic fracture management can be complicated, it may be good to focus on the causative factors and prevent occurrence with regular follow-up as often as possible in line with these factors.
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Affiliation(s)
| | - Selen Adiloglu
- Department of Oral and Maxillofacial Surgery, Hacettepe University, Ankara, Turkey
| | - Osman Taha Koseoglu
- Department of Oral and Maxillofacial Surgery, Hacettepe University, Ankara, Turkey
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20
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Laimer J, Hechenberger M, Lercher JM, Born E, Schomaker M, Puntscher S, Siebert U, Bruckmoser E. New Perspective for Soft Tissue Closure in Medication-Related Osteonecrosis of the Jaw (MRONJ) Using Barbed Sutures. J Clin Med 2021; 10:jcm10081677. [PMID: 33919696 PMCID: PMC8069803 DOI: 10.3390/jcm10081677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/03/2021] [Accepted: 04/11/2021] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to compare the effectiveness of barbed versus smooth sutures for soft tissue closure of exposed jawbone sites in medication-related osteonecrosis of the jaw (MRONJ) patients. Exposed necrotic jawbone sites surgically managed by intraoral soft tissue closure were evaluated. Either barbed sutures (Stratafix™ or V-Loc™) together with Prolene® or Vicryl® sutures were used. We estimated the effect of barbed sutures (BS) with Prolene® compared to smooth sutures (Vicryl®) on the hazard rate of intraoral soft tissue dehiscence using a multivariate Cox regression model within a target trial framework, adjusting for relevant confounders. In total, 306 operations were performed in 188 sites. In the primary analysis 182 sites without prior surgery were included. Of these, 113 sites developed a dehiscence during follow-up. 84 sites were operated using BS and Prolene®. A total of 222 sites were operated with Vicryl® (control group). In the BS group, the median time to event (i.e., dehiscence) was 148 days (interquartile range (IQR), 42–449 days) compared to 15 days (IQR, 12–52 days) in the control group. The hazard rate of developing intraoral dehiscence was 0.03 times (95%-confidence interval (CI): 0.01; 0.14, p < 0.001) lower for BS patients compared to the control group. Within the limits of a retrospective study, BS showed a high success rate and are therefore recommended for soft tissue closure of exposed jawbone sites in MRONJ patients. Additional studies are warranted to further evaluate this novel application of BS.
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Affiliation(s)
- Johannes Laimer
- University Hospital for Craniomaxillofacial and Oral Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria; (J.L.); (M.H.); (J.M.L.); (E.B.)
| | - Martin Hechenberger
- University Hospital for Craniomaxillofacial and Oral Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria; (J.L.); (M.H.); (J.M.L.); (E.B.)
| | - Johanna Maria Lercher
- University Hospital for Craniomaxillofacial and Oral Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria; (J.L.); (M.H.); (J.M.L.); (E.B.)
| | - Eva Born
- University Hospital for Craniomaxillofacial and Oral Surgery, Medical University Innsbruck, A-6020 Innsbruck, Austria; (J.L.); (M.H.); (J.M.L.); (E.B.)
| | - Michael Schomaker
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, A-6060 Hall in Tirol, Austria; (M.S.); (S.P.); (U.S.)
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, 7550 Cape Town, South Africa
| | - Sibylle Puntscher
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, A-6060 Hall in Tirol, Austria; (M.S.); (S.P.); (U.S.)
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, A-6060 Hall in Tirol, Austria; (M.S.); (S.P.); (U.S.)
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Emanuel Bruckmoser
- Private Practice for Oral and Maxillofacial Surgery, A-5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-677-63846310
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21
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Ikesue H, Doi K, Morimoto M, Hirabatake M, Muroi N, Yamamoto S, Takenobu T, Hashida T. Switching from zoledronic acid to denosumab increases the risk for developing medication-related osteonecrosis of the jaw in patients with bone metastases. Cancer Chemother Pharmacol 2021; 87:871-877. [PMID: 33791853 PMCID: PMC8110486 DOI: 10.1007/s00280-021-04262-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/16/2021] [Indexed: 01/02/2023]
Abstract
Purpose Switch from zoledronic acid (ZA) to denosumab may increase the risk of medication-related osteonecrosis of the jaw (MRONJ) owing to the additive effect of denosumab on the jawbone and residual ZA activities. We evaluated the risk of developing MRONJ in patients who received ZA, denosumab, or ZA-to-denosumab for the treatment of bone metastases. Methods The medical charts of patients with cancer who received denosumab or ZA for bone metastases were retrospectively reviewed. Patients who did not undergo a dental examination at baseline were excluded. Primary endpoint was the evaluation of the risk of developing MRONJ in the ZA-to-denosumab group. Secondary endpoints were probability of MRONJ and the relationship between risk factors and the time to the development of MRONJ. Results Among the 795 patients included in this study, 65 (8.2%) developed MRONJ. The incidence of MRONJ was significantly higher in the ZA-to-denosumab group than in the ZA group [7/43 (16.3%) vs. 19/350 (5.4%), p = 0.007]. Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment [hazard ratio (HR), 2.41; 95% confidence interval (CI), 1.37–4.39; p = 0.002], ZA-to-denosumab treatment (HR, 4.36; 95% CI, 1.63–10.54, p = 0.005), tooth extraction after starting ZA or denosumab (HR, 4.86; 95% CI, 2.75–8.36; p < 0.001), and concomitant use of antiangiogenic agents (HR, 1.78; 95% CI, 1.06–2.96; p = 0.030) were significant risk factors for MRONJ. Conclusion Our results suggest that switching from ZA to denosumab significantly increases the risk for developing MRONJ in patients with bone metastases. Supplementary Information The online version contains supplementary material available at 10.1007/s00280-021-04262-w.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Kohei Doi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Mayu Morimoto
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Pundole X, Jones AL, Tetzlaff MT, Williams MD, Murphy WA, Otun A, Goepfert RP, Davies MA. Osteonecrosis of the jaw induced by treatment with anti-PD-1 immunotherapy: a case report. Immunotherapy 2020; 12:1213-1219. [PMID: 32900256 PMCID: PMC7658614 DOI: 10.2217/imt-2020-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/26/2020] [Indexed: 01/15/2023] Open
Abstract
Recognizing rare but clinically significant toxicity of immunotherapy is critical. Here we describe the first detailed case of severe osteonecrosis of the jaw due to anti-PD-1. A 75-year-old man with metastatic melanoma, with no prior radiation or treatment with bone-targeting agents, experienced jaw pain 1 week after his first dose of nivolumab. Imaging studies were negative, and treatment was resumed after pain was controlled. 4 months later, the patient experienced acute exacerbation of pain and malocclusion of the jaw. Imaging showed bilateral fractures of the angle of mandible with extensive disruption of the normal trabecular architecture, requiring total mandibulectomy. The patient's metastatic melanoma responded to treatment and remains controlled >20 months after treatment cessation without further therapy.
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Affiliation(s)
- Xerxes Pundole
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Amy Little Jones
- Department of Internal Medicine, Division of Hematology-Oncology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Michael T Tetzlaff
- Department of Pathology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michelle D Williams
- Department of Pathology, the University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - William A Murphy
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Adegbenga Otun
- Section of Oral Oncology & Maxillofacial Prosthetics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ryan P Goepfert
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michael A Davies
- Department of Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Prevalence of medication related osteonecrosis of the jaw in patients treated with sequential antiresorptive drugs: systematic review and meta-analysis. Support Care Cancer 2020; 29:2305-2317. [PMID: 33190182 DOI: 10.1007/s00520-020-05882-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Antiresorptive drugs (ARD) are associated with a known serious adverse event, known as medication-related osteonecrosis of the jaws (MRONJ). Transition from one ARD to another has become common clinical practice with the advent of more potent or safer agents; however, the influence of sequential antiresorptive therapy as a risk factor for MRONJ has not been established. OBJECTIVES To investigate the prevalence of MRONJ in oncology or osteoporosis patients treated with two or more sequential ARDs as opposed to a single antiresorptive drug. MATERIAL AND METHODS Systematic electronic literature searches were conducted using Ovid MEDLINE, Ovid EMBASE, and Cochrane Central Register of Controlled Trials. Two review authors retrieved studies using pre-determined eligibility criteria and conducted quality assessment and data extraction. Fixed or random-effects meta-analysis models were used to summarize relative estimates for prevalence of MRONJ. RESULTS A total of 483 titles and abstracts were screened, and 18 full texts were retrieved for review. Twelve studies were included in the final qualitative and quantitative synthesis. Random effects meta-analysis models revealed a weighted pooled MRONJ prevalence of 19% (95% CI 10-27%) for sequential pamidronate-zoledronate therapy, 10% (95% CI 3-22%) for sequential ibandronate-zoledronate therapy. Pooled weighted prevalence of MRONJ was 13% (95% CI 3-22%) for sequential bisphosphonate-denosumab therapy while bisphosphonates only was 5% (95% CI 0-9%) and denosumab only was 4% (95% CI 3-5%). CONCLUSIONS The present systematic review suggests an increased prevalence of MRONJ associated with sequential ARD therapy for pamidronate-zoledronate and bisphosphonate-denosumab administration when compared to single ARD therapy.
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Pautke C, Wick A, Otto S, Hohlweg-Majert B, Hoffmann J, Ristow O. The Type of Antiresorptive Treatment Influences the Time to Onset and the Surgical Outcome of Medication-Related Osteonecrosis of the Jaw. J Oral Maxillofac Surg 2020; 79:611-621. [PMID: 33166522 DOI: 10.1016/j.joms.2020.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/06/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Few data exist focusing on differences in the time to disease onset and the success rates in patients suffering from medication-related osteonecrosis of the jaw (MRONJ) dependent on their different antiresorptive treatment. The purpose of this study was to analyze and compare these variables for patients treated with bisphosphonate (BP) or denosumab (DNO) and for patients who switched the antiresorptive drug (BP/DNO). PATIENTS AND METHODSS A retrospective single-center cohort study with patients suffering from MRONJ was conducted. The predictor variable was the antiresorptive treatment, the outcome variables were 1) time to onset of MRONJ (time of antiresorptive treatment to MRONJ diagnosis) and 2) treatment success (mucosal integrity 12 months postoperatively). The other variables include data on demographic, underlying disease, MRONJ stage, and trigger events. Cox and logistic regression, Phi-coefficient, Cramer's V, and Kruskal-Wallis tests were applied. RESULTS One hundred thirty-two patients were included and divided into 3 groups: group I (BP) n = 45 patients, n = 59 lesions; group II (BP/DNO) n = 42 patients, n = 71 lesions; and group III (DNO) n = 45 patients, n = 62 MRONJ lesions. Treatment success and time to onset differed significantly between the groups: success rates in group I BP (84.7%) were significantly lower (P = .04) than in group II BP/DNO (91.5%, P = .12) and group III DNO (90.3%, P = .35). The onset was significantly earlier in group III DNO (median 2.0 years, Q0.25: 1.49, Q0.75: 2.98; confidence interval 95%: 1.93 to 2.83) than in group II BP/DNO (median 4.07 years, Q0.25: 1.64, Q0.75: 6.70; confidence interval 95%: 3.55 to 5.68) and group I BP (median 3.86 years, Q0.25: 1.69, Q0.75: 6.46; confidence interval 95%: 3.43 to 5.87). CONCLUSIONS The different antiresorptive drugs show distinctive characteristics of time to onset and treatment success with the lowest success rates in the BP group and the earliest onset in the DNO group. The switch of the antiresorptive therapy (BP to DNO) did not influence the outcome variables negatively.
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Affiliation(s)
- Christoph Pautke
- Professor, Private Practitioner, Ludwig-Maximilians University Munich, Department of Oral and Maxillofacial Surgery Medizin & Aesthetik, Clinic for Oral and Maxillofacial and Plastic Surgery, Munich, Germany.
| | - Alexander Wick
- Resident, Medizin & Aesthetik, Clinic for Oral and Maxillofacial and Plastic Surgery, Munich, Germany
| | - Sven Otto
- Professor, Despartment of Oral and Maxillofacial Surgery, University of Halle, Halle, Germany
| | - Bettina Hohlweg-Majert
- Professor, Private Practitioner, Medizin & Aesthetik, Clinic for Oral and Maxillofacial and Plastic Surgery, Munich, Germany
| | - Jürgen Hoffmann
- Professor, Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Ristow
- Consultant, Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
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Otto S, Pautke C, Arens D, Poxleitner P, Eberli U, Nehrbass D, Zeiter S, Stoddart MJ. A Drug Holiday Reduces the Frequency and Severity of Medication-Related Osteonecrosis of the Jaw in a Minipig Model. J Bone Miner Res 2020; 35:2179-2192. [PMID: 32568416 PMCID: PMC7689727 DOI: 10.1002/jbmr.4119] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
Treatment of medication-related osteonecrosis of the jaw (MRONJ) is challenging and no clear consensus has been achieved. This study investigated preventive measures recommended for tooth extractions under antiresorptive (AR) treatment and the role of discontinuation of AR therapy to avoid the onset of MRONJ in a minipig model. Thirty-six Göttingen minipigs were divided into four groups. Group 1 (negative control): tooth extractions but no zoledronate (ZOL). Group 2 (positive control): weekly ZOL infusions for 12 weeks followed by tooth extractions without wound management followed by 8 weeks of ZOL treatment. Group 3: weekly ZOL infusions for 12 weeks followed by tooth extractions; surgical wound management (resection of sharp bone edges, mucoperiosteal coverage); and continuation of ZOL infusions for 8 weeks plus antibiotic treatment. Group 4: 12 weeks of ZOL infusions followed by a drug holiday for 6 weeks. Tooth extractions with preventive wound management followed by antibiotic treatment for 8 weeks but no ZOL infusions. Jawbones were subjected to macroscopic, radiological (CT and micro-CT) and histopathological investigations. No clinical cases of MRONJ were observed in the negative group, in the positive control all animals developed MRONJ. Group 3 developed MRONJ in 83% of cases. With a drug holiday, 40% developed MRONJ in areas of tooth extraction. This is the first large animal model that reduces the occurrence of MRONJ following tooth extraction by the implementation of a drug holiday combined with antibiotic prophylaxis and smoothening of sharp bony edges. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research..
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany
| | | | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Freiburg, Germany
| | | | | | | | - Martin J Stoddart
- AO Research Institute Davos, Davos, Switzerland.,Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Freiburg, Germany
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He L, Sun X, Liu Z, Qiu Y, Niu Y. Pathogenesis and multidisciplinary management of medication-related osteonecrosis of the jaw. Int J Oral Sci 2020; 12:30. [PMID: 33087699 PMCID: PMC7578793 DOI: 10.1038/s41368-020-00093-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious side effect of bone-modifying agents and inhibits angiogenesis agents. Although the pathogenesis of MRONJ is not entirely clear, multiple factors may be involved in specific microenvironments. The TGF-β1 signalling pathway may have a key role in the development of MRONJ. According to the clinical stage, multiple variables should be considered when selecting the most appropriate treatment. Therefore, the prevention and management of treatment of MRONJ should be conducted in patient-centred multidisciplinary team collaborative networks with oncologists, dentists and dental specialists. This would comprise a closed responsibility treatment loop with all benefits directed to the patient. Thus, in the present review, we aimed to summarise the pathogenesis, risk factors, imaging features, clinical staging, therapeutic methods, prevention and treatment strategies associated with MRONJ, which may provide a reference that can inform preventive strategies and improve the quality of life for patients in the future.
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Affiliation(s)
- Lina He
- The First Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Stomatology, Harbin Medical University, Harbin, China
| | - Xiangyu Sun
- The First Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Stomatology, Harbin Medical University, Harbin, China
| | - Zhijie Liu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Stomatology, Harbin Medical University, Harbin, China
| | - Yanfen Qiu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Stomatology, Harbin Medical University, Harbin, China
| | - Yumei Niu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China. .,School of Stomatology, Harbin Medical University, Harbin, China.
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27
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Mian M, Sreedharan S, Kumar R. Osteonecrosis of the jaws associated with protein kinase inhibitors: a systematic review. Oral Maxillofac Surg 2020; 25:149-158. [PMID: 33037971 DOI: 10.1007/s10006-020-00913-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/23/2020] [Indexed: 11/24/2022]
Abstract
This systematic review analysed evidence relating to medication-related osteonecrosis of the jaws (MRONJ) associated with protein kinase inhibitors in antiresorptive naïve patients. A literature search of major biomedical databases was conducted in March 2020. Information extracted from relevant articles included bibliographic information, patient characteristics, MRONJ characteristics at diagnosis, management strategies and outcomes. Sixteen studies, representing data from 17 patients, were included for final analysis. Descriptive statistics were used to synthesis available data. Eleven protein kinase inhibitors were implicated, with a mean exposure of 13 months prior to MRONJ. Renal cell carcinoma was the primary diagnosis in 41.2% of patients. Patient symptoms, clinical features, radiographic findings and histological findings were consistent with those previously described in patients with MRONJ associated with antiresorptive medications. Overall, there was a 75% rate of cure, with a mean healing time of 17.2 weeks. Patients were treated surgically in 53.3% of the cases. Patients treated surgically achieved complete healing in 100% of cases, compared with 58% in those treated conservatively. Drug discontinuation was reported in 69.2% of patients. Patients who had the offending drug discontinued achieved complete healing in 75% of cases, compared with 50% in those who did not. Evidence relating to MRONJ associated with protein kinase inhibitors is of low quality. From the available data, there are notable differences relating to patient characteristics, treatment strategies and outcomes, between MRONJ associated with protein kinase inhibitors compared with antiresorptives. Higher quality evidence is required to support the findings of this review.
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Affiliation(s)
- Mustafa Mian
- Royal Dental Hospital of Melbourne, 720 Swanston Street, Carlton, VIC, Australia. .,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.
| | | | - Ricky Kumar
- Royal Dental Hospital of Melbourne, 720 Swanston Street, Carlton, VIC, Australia.,Royal Melbourne Hospital, Melbourne, VIC, Australia
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28
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Werner Moeller Andersen S, Storgaard Jensen S, Schiodt M. Apical surgery in cancer patients receiving high-dose antiresorptive medication-a retrospective clinical study with a mean follow-up of 13 months. Oral Maxillofac Surg 2020; 25:237-246. [PMID: 32970228 DOI: 10.1007/s10006-020-00909-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/11/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The aim of the study is to evaluate the results of apical surgery (AS) in patients receiving high-dose antiresorptive medication (HDAR). METHODS Retrospective descriptive quality control study conducted in an Oral and Maxillofacial Department at a University Hospital. Fourteen patients on HDAR met the inclusion criteria. Only descriptive statistics were applied. RESULTS Fourteen patients had operation on seventeen teeth. Mean HDAR treatment period before apical surgery: 25 months (SD, ± 24.27; range, 1-78 months). Drug holiday during surgery and initial healing: mean, 8 months (SD, ± 5.96; range, 0.4-22 months). Sixteen out of seventeen teeth healed clinically and showed complete or ongoing radiographic healing. All patients except one became free of symptoms. Mean follow-up: 13 months (SD, ± 9.05; range, 2-31 months). Radiographic healing according to Molven and Rud: 7, complete; 6, uncertain; 1, unsatisfactory. Three patients died during follow-up and were considered drop-outs. CONCLUSIONS The present case series suggest that apical surgery is a valid treatment option for apical periodontitis in patients on HDAR, where orthograde endodontic retreatment is not possible. None of the patients developed medication-related osteonecrosis of the jaw. Further studies in larger study groups and with longer follow-up periods are needed. The regional scientific ethical committee provided a document exemption, registration date 20 November 2013, and the local data protection agency approved handling of the recorded data (No. 2012-41-0045), registration date 11 January 2012.
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Affiliation(s)
- Sanne Werner Moeller Andersen
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Simon Storgaard Jensen
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Oral Surgery, School of Dentistry, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Alle 20, 2200, Copenhagen, Denmark
| | - Morten Schiodt
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, 8200, Aarhus, Denmark
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29
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Drudge-Coates L, Van den Wyngaert T, Schiødt M, van Muilekom HAM, Demonty G, Otto S. Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals. Support Care Cancer 2020; 28:4019-4029. [PMID: 32307659 PMCID: PMC7378104 DOI: 10.1007/s00520-020-05440-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/27/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care. METHODS We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals. RESULTS While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ. CONCLUSIONS This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.
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Affiliation(s)
- Lawrence Drudge-Coates
- Department of Urology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Morten Schiødt
- Department of Oral and Maxillofacial Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - H A M van Muilekom
- Department of Urology, Antoni van Leeuwenhoek Hospital-Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Gaston Demonty
- Medical Development, Amgen (Europe) GmbH, Rotkreuz, Switzerland
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
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30
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Ristow O, Rückschloß T, Moratin J, Müller M, Kühle R, Dominik H, Pilz M, Shavlokhova V, Otto S, Hoffmann J, Freudlsperger C. Wound closure and alveoplasty after preventive tooth extractions in patients with antiresorptive intake-A randomized pilot trial. Oral Dis 2020; 27:532-546. [PMID: 32875698 DOI: 10.1111/odi.13556] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/09/2020] [Accepted: 07/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To compare success rates between the sub-periosteal prepared (SPP) muco-periosteal flap and the epi-periosteal prepared (EPP) mucosa flap and the feasibility of alveoplasty after surgical tooth extractions in patients undergoing/after antiresorptive treatment. SUBJECTS Patients with an indication for preventive tooth extraction undergoing/after antiresorptive treatment were enrolled over a 24-month period in a parallel-group randomized clinical pilot trial and randomly assigned for primary wound closure to either the SPP or the EPP group. The primary outcome was treatment failure 8 weeks after surgery. To assess the feasibility of alveoplasty, necrotic bone changes at the time point of tooth extraction were evaluated. RESULTS One hundred and sixty patients were randomized to the SSP (n = 82) or the EPP (n = 78) group. One hundred and fifty-seven patients met the primary endpoint 8 weeks after surgery with five treatment failures for the SPP group (6.3%) and 18 (23.4%) for the EPP group (p = .004). A significant relationship (p < .0001) was observed between symptomatic teeth and non-vital bone found in 54.8% of all biopsies. CONCLUSIONS The strong superiority of the muco-periosteal flap as primary wound closure revealed the feasibility and effectiveness of the study. The large number of necrotic biopsies emphasizes the importance of alveoplasty as a preventive measure.
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Affiliation(s)
- Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Rückschloß
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julius Moratin
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Michael Müller
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Reinald Kühle
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Horn Dominik
- Department of Oral and Maxillofacial Surgery, Saarland University, Homburg, Germany
| | - Maximilian Pilz
- Department of Biometry, Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Veronika Shavlokhova
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
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31
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Nicolatou‐Galitis O, Papadopoulou E, Vardas E, Kouri M, Galiti D, Galitis E, Alexiou K, Tsiklakis K, Ardavanis A, Razis E, Athanasiadis I, Droufakou S, Psyrri A, Karamouzis MV, Linardou H, Daliani D, Tzanninis D, Sachanas S, Laschos K, Kyrtsonis M, Antoniou F, Laskarakis A, Giassas S, Nikolaidi A, Rigakos G, Ntokou A, Migliorati CA, Ripamonti CI. Alveolar bone histological necrosis observed prior to extractions in patients, who received bone‐targeting agents. Oral Dis 2020; 26:955-966. [DOI: 10.1111/odi.13294] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 12/26/2019] [Accepted: 01/28/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Ourania Nicolatou‐Galitis
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Erofili Papadopoulou
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Emmanouil Vardas
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Maria Kouri
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Dimitra Galiti
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | - Evangelos Galitis
- Clinic of Oral and Maxillofacial Surgery Dental School National & Kapodistrian University of Athens Athens Greece
| | - Konstantina‐Eleni Alexiou
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | - Kostas Tsiklakis
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | | | - Evangelia Razis
- Third Medical Oncology Department Hygeia Hospital Athens Greece
| | | | | | - Amanda Psyrri
- Attikon Hospital National and Kapodistrian University of Athens Athens Greece
| | - Michalis V. Karamouzis
- Department of Biological Chemistry and First Department of Internal Medicine Laikon Hospital, Medical School National and Kapodistrian University of Athens Athens Greece
| | | | - Danai Daliani
- First Medical Oncology Department Euroclinic of Athens Athens Greece
| | | | - Sotirios Sachanas
- Department of Hematology Athens Medical Center Psychikon Branch Athens Greece
| | - Konstantinos Laschos
- 2nd Oncology Department General and Oncologic Hospital “Agii Anargyri” Athens Greece
| | | | - Fotini Antoniou
- Department of Oncology Unit Elena Venizelou Maternity Hospital Athens Greece
| | | | - Styllianos Giassas
- 2nd Oncology Clinic IASO Maternity Hospital and 3rd Oncology Clinic Metropolitan General Hospital Athens Greece
| | | | - George Rigakos
- Third Medical Oncology Department Hygeia Hospital Athens Greece
| | - Anna Ntokou
- Oncology Department Saint Savvas Hospital Athens Greece
| | - Cesar A. Migliorati
- Department of Diagnostic Sciences and Oral Medicine University of Florida Health Science Center College of Dentistry Gainesville FL USA
| | - Carla I. Ripamonti
- Supportive Care Unit Department of Medical Oncology and Haematology Fondazione IRRCS Istituto Nazionale dei Tumori Milano Italy
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Vereb T, Boda K, Czakó L, Vaszilkó M, Fülöp G, Klenk G, Janovszky Á, Oberna F, Piffkó J, Seres L. Cloud-Based Multicenter Data Collection and Epidemiologic Analysis of Bisphosphonate-Related Osteonecrosis of the Jaws in a Central European Population. J Clin Med 2020. [DOI: https://doi.org/10.3390/jcm9020426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: Bisphosphonate-related osteonecrosis of the jaws is considered to be a rare but severe complication of bisphosphonate therapy. To understand this condition better, data collection is essential. Although the number of scientific papers about this subject is large, to date only a few multicenter reports have been published. Study design: We present a novel cloud-based data collection system for the evaluation of the risk factors of bisphosphonate-related osteonecrosis of the jaws. Web-based questionnaire and database have been set up and made available to voluntary researchers and clinicians in oral and maxillofacial surgery in Hungary and Slovakia. Results: To date, fifteen colleagues from eight maxillofacial units have joined the study. Data of 180 patients have been recorded. Collected data were statistically analysed and evaluated from an epidemiological point of view. Conclusions: Authors consider cloud-based multicenter data collection a useful tool that allows for real-time collaboration between users, facilitates fast data entry and analysis, and thus considerably contributes to widening our knowledge of bisphosphonate-related osteonecrosis of the jaws.
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Cloud-Based Multicenter Data Collection and Epidemiologic Analysis of Bisphosphonate-Related Osteonecrosis of the Jaws in a Central European Population. J Clin Med 2020; 9:jcm9020426. [PMID: 32033299 PMCID: PMC7073980 DOI: 10.3390/jcm9020426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 12/01/2022] Open
Abstract
Objective: Bisphosphonate-related osteonecrosis of the jaws is considered to be a rare but severe complication of bisphosphonate therapy. To understand this condition better, data collection is essential. Although the number of scientific papers about this subject is large, to date only a few multicenter reports have been published. Study design: We present a novel cloud-based data collection system for the evaluation of the risk factors of bisphosphonate-related osteonecrosis of the jaws. Web-based questionnaire and database have been set up and made available to voluntary researchers and clinicians in oral and maxillofacial surgery in Hungary and Slovakia. Results: To date, fifteen colleagues from eight maxillofacial units have joined the study. Data of 180 patients have been recorded. Collected data were statistically analysed and evaluated from an epidemiological point of view. Conclusions: Authors consider cloud-based multicenter data collection a useful tool that allows for real-time collaboration between users, facilitates fast data entry and analysis, and thus considerably contributes to widening our knowledge of bisphosphonate-related osteonecrosis of the jaws.
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Yarom N, Shapiro CL, Peterson DE, Van Poznak CH, Bohlke K, Ruggiero SL, Migliorati CA, Khan A, Morrison A, Anderson H, Murphy BA, Alston-Johnson D, Mendes RA, Beadle BM, Jensen SB, Saunders DP. Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:2270-2290. [PMID: 31329513 DOI: 10.1200/jco.19.01186] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer. METHODS Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included. RESULTS The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting. RECOMMENDATIONS Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
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Affiliation(s)
- Noam Yarom
- Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Salvatore L Ruggiero
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY.,Stony Brook School of Dental Medicine, Stony Brook, NY.,New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | - Aliya Khan
- McMaster University, Hamilton, Ontario, Canada
| | - Archie Morrison
- Dalhousie University, Halifax, Nova Scotia, Canada.,Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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von Moos R, Costa L, Gonzalez-Suarez E, Terpos E, Niepel D, Body JJ. Management of bone health in solid tumours: From bisphosphonates to a monoclonal antibody. Cancer Treat Rev 2019; 76:57-67. [PMID: 31136850 DOI: 10.1016/j.ctrv.2019.05.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/23/2019] [Accepted: 05/13/2019] [Indexed: 02/06/2023]
Abstract
Patients with solid tumours are at risk of impaired bone health from metastases and cancer therapy-induced bone loss (CTIBL). We review medical management of bone health in patients with solid tumours over the past 30 years, from first-generation bisphosphonates to the receptor activator of nuclear factor κB ligand (RANKL)-targeted monoclonal antibody, denosumab. In the 1980s, first-generation bisphosphonates were shown to reduce the incidence of skeletal-related events (SREs) in patients with breast cancer. Subsequently, more potent second- and third-generation bisphosphonates were developed, particularly zoledronic acid (ZA). Head-to-head studies showed that ZA was significantly more effective than pamidronate for reducing SREs in patients with breast and castrate-resistant prostate cancer (CRPC), becoming the standard of care for more than a decade. The RANKL inhibitor denosumab was licensed in 2010, and head-to-head studies and integrated analyses confirmed its superiority to ZA for preventing SREs, particularly in breast cancer and CRPC. Bisphosphonates and denosumab have also been investigated for prevention of CTIBL in patients receiving hormonal therapy for breast and prostate cancer, and denosumab is licensed in this indication. Despite advances in management of bone health, several issues remain, notably the optimal time to initiate therapy, duration of therapy, and dosing frequency, and how to avoid toxicity, particularly with long-term treatment. In summary, introduction of ZA and denosumab has protected patients with bone metastasis from serious bone complications and improved their quality of life. Ongoing research will hopefully guide the optimal use of these agents to help maintain bone health in patients with solid tumours.
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Affiliation(s)
- Roger von Moos
- Kantonsspital Graubünden, Loëstrasse 170, Chur, Graubünden, Switzerland.
| | - Luis Costa
- Hospital de Santa Maria, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Eva Gonzalez-Suarez
- Cancer Epigenetics and Biology Program (PEBC), Bellvitge Biomedical Research Institute, (IDIBELL) Avinguda Gran Via de l'Hospitalet, Barcelona, Spain
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Place A. Van Gehuchten 4, 1020 Brussels, Belgium
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Comorbid conditions are a risk for osteonecrosis of the jaw unrelated to antiresorptive therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 127:140-150. [DOI: 10.1016/j.oooo.2018.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/23/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
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Ristow O, Rückschloß T, Müller M, Berger M, Kargus S, Pautke C, Engel M, Hoffmann J, Freudlsperger C. Is the conservative non-surgical management of medication-related osteonecrosis of the jaw an appropriate treatment option for early stages? A long-term single-center cohort study. J Craniomaxillofac Surg 2018; 47:491-499. [PMID: 30642734 DOI: 10.1016/j.jcms.2018.12.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/29/2018] [Accepted: 12/21/2018] [Indexed: 11/26/2022] Open
Abstract
PURPOSE No consensus has been reached regarding the best treatment option for early-stage lesions in medication-related osteonecrosis of the jaw (MRONJ). The purpose of the present study was to evaluate the long-time outcomes of conservative non-surgical management in stage I patients with underlying malignant disease. MATERIALS AND METHODS We designed and implemented a retrospective cohort study and enrolled, between 2008 and 2018, a sample of patients with the indication for non-surgical conservative treatment stage I lesions. The primary outcome variable was treatment success defined as mucosal integrity without signs of infection. Secondary outcomes were: (i) worsening stage, (ii) necessity for surgical intervention over time, and (iii) discontinuation of antiresorptive therapy. RESULTS The sample included 75 patients with 92 lesions. Eight lesions showed full mucosal coverage, whereas 84 continued with exposed jaw bone (91.3%). Of the treatment-resistent 84 lesions, 67 presented a worsening stage shift over time. Indication for surgical intervention was set in 57 lesions. Of all lesions, 28 developed highly advanced necrotic bone destruction. Antiresorptive medication was paused in all evaluated patients after the first diagnosis of MRONJ. CONCLUSION Conservative non-surgical therapy in MRONJ stage I leads to a healing in rare cases. Conservative management might be a good option to preserve symptoms in patients either unwilling to undergo surgery or in those whose reduced general condition does not allow surgery. Early and consequent surgical advances should be performed throughout all stages of the disease to prevent the possibility of silent disease progression with the risk of large-scale bone loss.
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Affiliation(s)
- Oliver Ristow
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany.
| | - Thomas Rückschloß
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Michael Müller
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Moritz Berger
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Steffen Kargus
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Christoph Pautke
- University of Munich, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. M. Ehrenfeld), Lindwurmstr. 2a, 80337, München, Germany
| | - Michael Engel
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Jürgen Hoffmann
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Christian Freudlsperger
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
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Nicolatou-Galitis O, Kouri M, Papadopoulou E, Vardas E, Galiti D, Epstein JB, Elad S, Campisi G, Tsoukalas N, Bektas-Kayhan K, Tan W, Body JJ, Migliorati C, Lalla RV. Osteonecrosis of the jaw related to non-antiresorptive medications: a systematic review. Support Care Cancer 2018; 27:383-394. [PMID: 30353228 DOI: 10.1007/s00520-018-4501-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/03/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The reporting of osteonecrosis of the jaw (ONJ) related to anticancer agents without known antiresorptive properties (non-antiresorptives), such as antiangiogenics, tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, immune checkpoint inhibitors, and cytotoxic chemotherapy is increasing. OBJECTIVE To review characteristics of ONJ in cancer patients receiving non-antiresorptives. METHODS A systematic review of the literature between 2009 and 2017 was conducted by the Bone Study Group of MASCC/ISOO. RESULTS Of 6249 articles reviewed and from personal communication, 42 ONJ cases related to non-antiresorptives were identified. No gender predilection was noted. Median age was 60 years and ONJ stage 2 was most common, with predilection for posterior mandible. Exposed bone, pain, and infection were common at diagnosis. In comparison to bone targeting agents (BTAs), radiology, histology, and management were similar, with medication often discontinued. Delayed diagnosis (median 8 weeks) was noted. Important differences included earlier time to ONJ onset (median 20 weeks), absence of trigger event (40%), and greater likelihood of healing and shorter healing time (median 8 weeks) as compared to BTA-related ONJ. Gastrointestinal cancers predominated, followed by renal cell carcinomas compared to breast, followed by prostate cancers in BTA-related ONJ, reflecting different medications. CONCLUSIONS Data about non-antiresorptive-related ONJ is sparse. This type of ONJ may have better prognosis compared to the BTA-related ONJ, suggested by greater likelihood of healing and shorter healing time. However, the delay in diagnosis highlights the need for more education. This is the first attempt to characterize ONJ associated with different non-antiresorptives, including BRAF and immune checkpoint inhibitors.
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Affiliation(s)
- Ourania Nicolatou-Galitis
- Dental School, National and Kapodistrian University of Athens, Bouboulinas 41, N. Psyhico, 154 51, Athens, Greece.
| | - Maria Kouri
- Dental School, National and Kapodistrian University of Athens, Bouboulinas 41, N. Psyhico, 154 51, Athens, Greece
| | - Erofili Papadopoulou
- Dental School, National and Kapodistrian University of Athens, Bouboulinas 41, N. Psyhico, 154 51, Athens, Greece
| | - Emmanouil Vardas
- Dental School, National and Kapodistrian University of Athens, Bouboulinas 41, N. Psyhico, 154 51, Athens, Greece
| | - Dimitra Galiti
- Dental School, National and Kapodistrian University of Athens, Bouboulinas 41, N. Psyhico, 154 51, Athens, Greece
| | - Joel B Epstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Health System, Los Angeles CA and City of Hope National Medical Center, Duarte, CA, USA
| | - Sharon Elad
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Giuseppina Campisi
- Sector of Oral Medicine "V. Margiotta", Department Di.Chir.On.S, University of Palermo, Palermo, Italy
| | - Nikolaos Tsoukalas
- Consultant Medical Oncologist, Oncology Department, Veterans Hospital (NIMTS), Athens, Greece
| | - Kivanc Bektas-Kayhan
- Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey
| | - Winston Tan
- Hematology/Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Cesar Migliorati
- Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Rajesh V Lalla
- Section of Oral Medicine, University of Connecticut School of Dental Medicine, Farmington, CT, USA
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Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis, and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 127:117-135. [PMID: 30393090 DOI: 10.1016/j.oooo.2018.09.008] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/16/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022]
Abstract
Skeletal complications caused by osteoporosis or bone metastases are associated with considerable pain, increased mortality, and reduced quality of life. Furthermore, such events place a burden on health care resources. Agents that prevent bone resorption, such as bisphosphonates or denosumab, can reduce the risk of skeletal-related events and are widely used in patients with osteoporosis or bone metastases of cancer. Medication-related osteonecrosis of the jaw (MRONJ) is a rare, but potentially serious, adverse event associated with high cumulative doses of bisphosphonates or denosumab. However, MRONJ can be treated, and the likelihood of the development of this condition can be reduced through prophylactic dental care and the maintenance of good oral hygiene. Dentists, as part of a multiprofessional team, have a critical role in preventing MRONJ. This review describes the incidence and pathophysiology of MRONJ and provides guidance for dental practitioners with regard to the screening, prophylactic treatment, diagnosis, and management of patients with this condition.
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Otto S, Pautke C, Van den Wyngaert T, Niepel D, Schiødt M. Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases. Cancer Treat Rev 2018; 69:177-187. [PMID: 30055439 DOI: 10.1016/j.ctrv.2018.06.007] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 01/12/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is primarily an adverse side effect of denosumab or bisphosphonates (particularly when used at high doses to prevent skeletal-related events [SREs] in patients with cancer and bone metastases) or possibly anti-angiogenic cancer treatment. While the implementation of preventive measures over recent years has reduced the risk of MRONJ in patients with bone metastases due to cancer, it is imperative to balance the risk of MRONJ against the beneficial effects of treatment with denosumab or bisphosphonates on the skeletal health of patients. Despite growing awareness of MRONJ within the medical community, there is a lack of large-scale, prospective clinical studies in this rapidly evolving field. Discussing preventive measures with patients and implementing them, both before and during treatment with bisphosphonates or denosumab, is the best option to reduce the risk of MRONJ. In particular, avoiding bone trauma and preventing and treating dental infections before and during denosumab or bisphosphonate therapy is crucial to minimize the risk of MRONJ. If MRONJ develops, conservative (non-surgical) treatment can provide symptom relief, but achieving mucosal closure remains challenging. When management of symptoms and mucosal healing are the ultimate goals of therapy, or after failure of conservative treatment, a surgical approach may be beneficial. This critical review, based on a best-evidence review of currently available literature, provides clear practical guidelines to help to prevent, manage and treat MRONJ. Overall, a multidisciplinary, pragmatic approach to MRONJ should be adopted, prioritizing patient's quality of life and management of their skeletal malignant disease.
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium; Molecular Imaging Center Antwerp, University of Antwerp, Antwerp, Belgium.
| | | | - Morten Schiødt
- Department of Oral and Maxillofacial Surgery, Rigshospitalet, Copenhagen, Denmark.
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