Patients’ quality of life improves after surgical intervention of stage III medication-related osteonecrosis of the jaw

The Role of Cone Beam Computed Tomography (CBCT) in the Diagnosis and Clinical Management of Medication-Related Osteonecrosis of the Jaw (MRONJ)

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating condition associated with antiresorptive and antiangiogenic medications that are frequently used in treating osteoporosis and cancers. With the ability to produce high-resolution images with a lower radiation dose, cone beam computed tomography (CBCT) is an emerging technology in maxillofacial imaging that offers several advantages in evaluating MRONJ. This review aims to summarise the radiological features of MRONJ as observed via CBCT and highlight its advantages over two-dimensional plain films in assessing MRONJ. CBCT has the capability to detect early MRONJ lesions, characterise the extent and nature of lesions, distinguish MRONJ from other osseous pathologies, and assist in treatment planning. By leveraging the advantages of CBCT, clinicians can enhance their understanding of MRONJ, improve decision making, and ultimately optimize patient care.

Oral Health-Related Quality of Life and Mental Health Impairment in Patients Affected by Medication-Related Osteonecrosis of the Jaws: A Case-Control Pilot Study

In the present case-control study, the impact of medication-related osteonecrosis of the jaws (MRONJ) on patients' oral health-related quality of life (OHRQoL), overall quality of life (QoL), and psychological status was evaluated using a set of questionnaires. These questionnaires included the Oral Health Impact Profile-14 (OHIP-14), the Short Form 36 Health Survey Questionnaire (SF-36), and the hospital anxiety and depression scale (HADS). A total of 25 MRONJ patients and 25 controls were included in the study. The results showed that MRONJ patients had a significantly poorer OHRQoL (OHIP-14 score p-value: 0.003) and lower general QoL, particularly in the domains of "physical functioning", "physical role", "body pain", "general health", and "vitality" in the SF-36 questionnaire (p-values: 0.001, 0.001, 0.013, 0.001, and 0.020). Although there were no significant differences between the groups in the SF-36 domains of "social functioning", "emotional role", and "mental health", the mean sub-scores of the HADS, specifically the depression and anxiety scores (HADS-D and HADS-A), were significantly higher in MRONJ patients (p-values: 0.002 and 0.009). However, the "mental health" domain of the SF-36 questionnaire showed a correlation with both HADS-A and HADS-D scores (p-values: 0.003 and 0.031). Therefore, a comprehensive clinical examination of MRONJ patients should include the assessment of OHRQoL, overall QoL, and psychological profile using different questionnaires. This approach aims to gather detailed information about patients' physical and psychological well-being, enabling the development of tailored treatments.

Associated systemic diseases and etiologies of medication-related osteonecrosis of the jaw: a retrospective study of 265 surgical cases

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is one of the complications caused by various drugs. As there are increasing reports of MRONJ, it is important to diagnose and identify patients who have the potential risk of the disease. The aim of this study was to analyze the systemic diseases, etiology, and treatment results of MRONJ.

MATERIAL AND METHODS

A total of 265 MRONJ operations were reviewed retrospectively. This study included patients who were diagnosed as MRONJ and those who also received surgery, ranging from simple extraction to reconstruction with free flaps, from 2009 to 2021. Each patient's systemic disease and eitology and basic demographic information was taken into consideration.

RESULTS

The most common diseases related were osteoporosis (n = 127), breast cancer (n = 77), multiple myeloma (n = 27), prostate cancer (n = 26), and etc. (n = 12). The related causes of MRONJ were extraction (n = 138), implants (n = 40), and irritations by prosthesis (n = 29); however, 55 cases were occurred spontaneously. Out of 265 patients, 214 were women while 51 were men. The average age when the surgery took place was 67.7 and 69.8 years for male and female patients, respectively. Saucerization and sequestrectomy (n = 252) was the most common surgical treatment, followed by mandibulectomy (n = 12) and partial maxillectomy (n = 1). While 4 cases occurred in both jaws, 168 cases were in the mandible and 93 cases were in the maxilla.

CONCLUSION

Nearly 50 % of the MRONJ patients had osteoporosis and the other patients who received bone targeting agents parentral had bone metastasis of various cancers. Extraction is the most common related event for MRONJ.

Comparing the Influence of Surgical and Conservative Therapy on Quality of Life in Patients with Early-Stage Medication-Related Osteonecrosis of the Jaw-A Prospective Longitudinal Study

Background and Objectives: The purpose of this study was to evaluate the impact of surgical and conservative, non-surgical treatment on general health-related (QoL) and oral health-related quality of life (OHRQoL) in patients suffering from AAOMS stage I MRONJ. Materials and Methods: In the course of this prospective clinical study, QoL and OHRQoL using QLQ-C30 and QHIP G14 questionnaire were longitudinally assessed in N = 174 prospectively enrolled patients with indication of treatment of MRONJ stage I over a period of 12 months. Patients received conservative or surgical treatment. The measurement time points were preoperatively (T0), 12 weeks (T1), 6 months (T2) and 1 year after operation (T3). Results: For OHRQoL, no significant (p > 0.05) differences were found between both treatment groups for all timepoints (T0-T3). In the surgical treatment group, OHIP scores of T1, T2 and T3 were significantly lower than baseline measures (T0) (T0-T1 (2.99, p = 0.024), T0-T2 (5.20, p < 0.001), T0-T3 (7.44, p < 0.001)). For conservative treatment group OHIP, scores of T2 and T3 were significantly lower than baseline measures (T0) (T0-T2 (9.09, p = 0.013), T0-T3 (12.79, p < 0.001)). There was no statistically significant effect of time on QLQ-C30 scores in both groups (surgical treatment: F(3, 174) = 1.542, p < 0.205, partial η² = 0.026; conservative treatment: F(3, 30) = 0.528, p = 0.667, partial η² = 0.050). QLQ-C30 scores turned out to be significantly lower in the non-surgical group at T1 (p = 0.036) and T3 (p = 0.047) compared to the surgical treatment group. Conclusions: Surgical and conservative treatment of MRONJ stage I significantly improves patients' OHRQoL. Surgical treatment is superior to conservative treatment of MRONJ stage I regarding general QoL. Therefore, surgical treatment of MRONJ stage I should not be omitted for QoL reasons.

Quality of life after segmental mandibulectomy and free flap for mandibular osteonecrosis: Systematic review

OBJECTIVE

Review QOL outcomes among patients undergoing segmental mandibulectomy and bony free flap reconstruction for ONJ.

DATA SOURCES

PubMed was searched for MeSH terms "Quality of life," "Osteonecrosis," "Osteoradionecrosis," "Bisphosphonate-associated osteonecrosis of the jaw," "Free tissue flaps," and "Mandibular reconstruction."

REVIEW METHODS

English language studies with QOL outcomes data for patients undergoing free flap reconstruction for advanced ONJ were included. 197 records were initially screened; 18 full texts assessed; 10 full texts included. PRISMA guidelines were followed.

RESULTS

Ten studies were included in this systematic review: six retrospective, three retrospective with comparison groups, and one prospective. In studies with comparison groups, ONJ patients have worse self-reported QOL than the general population as well as head and neck cancer patients without ONJ. Nearly all patients with QOL measurements (220/235 patients) had ONJ from prior radiation. Segmental mandibulectomy and bony free flap improved overall QOL in over half of patients, as well as pain associated with ONJ in 70-75 % of patients. Surgery did not improve long-term effects of radiation such as chewing, swallowing, and salivary production. Donor site morbidity rarely affects QOL.

CONCLUSIONS

Osteonecrosis of the jaw (ONJ) worsens quality-of-life, and advanced disease often requires segmental mandibulectomy and bony free flap reconstruction. Patients and surgeons may expect improvement in some, but not all, domains of patient-reported QOL by the use of segmental mandibulectomy and reconstruction for advanced ONJ.

Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS

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.

Development and evaluation of the clinimetric properties of the Medication-Related Osteonecrosis of the Jaw Quality of Life Questionnaire (MRONJ-QoL)

The purpose of this study was to develop a self-administered questionnaire (MRONJ-QoL) to assess the quality of life (QoL) of patients with medication-related osteonecrosis of the jaw (MRONJ). A prospective study was performed to develop and evaluate the questionnaire. The MRONJ-QoL was formulated through a review of the literature and interviews of experts and patients. Following development, it was administered to 60 patients with a diagnosis of MRONJ. The sensibility of the questionnaire was assessed by evaluating feasibility (via interviews of patients), face validity (via interviews of patients and experts), and content validity (via evaluation of internal consistency, floor/ceiling effects, and factor analysis). Reliability was evaluated by measuring intra-rater reliability. Construct validity of the questionnaire was evaluated by both cross-sectional and longitudinal comparisons, including comparing scores of the MRONJ-QoL to disease resolution at 6 months. The final MRONJ-QoL questionnaire consisted of 14 questions, demonstrating high internal consistency (Cronbach's alpha of 0.85) and good reliability (weighted kappa score of 0.65). At the 6-month follow-up, disease resolution was found to be significantly associated with improved MRONJ-QoL scores, suggesting validity of the questionnaire (P < 0.01). Therefore, this is a sensible, reliable, and valid questionnaire for evaluating the QoL of patients with MRONJ.

Influence of Preventive Tooth Extractions on Quality of Life in Patients with Antiresorptive Intake-A Prospective Longitudinal Study

Background: To find out whether preventive tooth extractions in patients on antiresorptive therapy have a direct impact on the patients’ overall quality of life (QoL); Methods: QoL using the five-level version of the EuroQol Group’s EQ-5D instrument (EQ-5D-5L) was longitudinally assessed in N = 114 prospectively enrolled patients with indication of preventive tooth extraction over a period of 12 months. Patients were stratified as high-risk (malignant disease with bone metastasis or multiple myeloma, with monthly high-dose antiresorptive therapy delivered intravenously [bisphosphonate] or subcutaneously [denosumab]) and low-risk/osteoporosis patients (weekly low-dose antiresorptive therapy administered orally [bisphosphonate] or half-yearly subcutaneously [denosumab]). The measurement time points were 4 weeks preoperatively (T0), 2 months (T1) and 1 year postoperatively (T2), respectively. Results: EQ-5D-5L index scores fell in a range from −0.21 to 1.00 in the low-risk group to 0.15 to 1.00 in the high-risk group. The t-test comparing the baseline index scores of both groups showed EQ-5D-5L index score in the low-risk group (0.708 ± 0.292) to be significantly smaller (p = 0.037) than in the high-risk group (0.807 ± 0.19). ANCOVA showed no significant differences in EQ-5D-5L index scores between the groups at T1 and T2. Conclusions: Preventive tooth extractions in patients undergoing antiresorptive treatment have no negative effect on QoL. Therefore, if indicated, preventive tooth extraction should not be omitted. Patient-oriented outcome measures are important to obtain a good risk–benefit balance for patient-specific treatment.

Quality of life in patients affected by medication-related osteonecrosis of the jaws: A systematic review

OBJECTIVE

The aim of this systematic review was to describe the quality of life and oral health-related quality of life of patients affected by medication-related osteonecrosis of the jaw.

STUDY DESIGN

The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A combination of keywords and MeSH terms was used in PubMed, Scopus, Cochrane Library, Web of Science, and EBSCO up to December 13, 2020.

RESULTS

A total of 1066 results were obtained after duplicate exclusion and 11 articles were included in the final qualitative analysis. Most of the articles described the quality of life in patients with osteonecrosis of the jaw secondary to cancer treatment. The main drugs associated with the disease were bisphosphonates. Surgical treatment of the osteonecrosis improves the quality of life of these patients.

CONCLUSIONS

The present systematic review suggested the negative influence of osteonecrosis of the jaw on the quality of life and oral health-related quality of life among oncologic and osteoporotic patients. The use of quality of life questionnaires in daily practice could be an important tool to better diagnose and manage patients affected by osteonecrosis of the jaws who have received or are receiving drugs associated with this complication.