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Miyoshi T, Otsuru M, Morishita K, Omori K, Miura KI, Hayashida S, Rokutanda S, Matsushita Y, Umeda M, Yamada T. Differences Between Medication-Related Osteonecrosis of the Jaw Caused by Bisphosphonates and Denosumab: Histological, Molecular Biological, and Clinical Studies. Cureus 2024; 16:e62855. [PMID: 39036251 PMCID: PMC11260442 DOI: 10.7759/cureus.62855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/23/2024] Open
Abstract
Purpose Medication-related osteonecrosis of the jaw (MRONJ) is a serious side effect of antiresorptive agents such as bisphosphonates (BPs) and denosumab (DMB). We investigated whether a difference exists between BP- and DMB-related osteonecrosis of the jaw (ONJ). Patients and methods Histological images of 30 patients with BP-related ONJ and 13 patients with DMB-related ONJ were observed using hematoxylin-eosin and cathepsin K staining. Moreover, bone metabolism markers in the blood and bone mineral density were measured in 18 patients with BP-related ONJ and five patients with DMB-related ONJ. Furthermore, we conducted a quantitative analysis of local bone metabolism-related genes using surgical specimens through real-time reverse transcription polymerase chain reaction. Additionally, a retrospective study of 298 patients with MRONJ examined the differences in the characteristics of BP- and DMB-related ONJ and the factors associated with treatment outcomes. Results Histological examination revealed that patients treated with DMB had more severe osteoclast suppression than those treated with BP. No significant difference was observed in blood-bone metabolism markers between the two drugs; however, the suppression of local bone metabolism-related genes was stronger in patients treated with DMB. Clinical studies indicate that DMB-related ONJ is more frequently observed without osteolysis. Conclusion BP-associated ONJ and DMB-associated ONJ were shown to differ slightly. Clinical studies indicate that osteolysis is often unclear in DMB-related ONJ, and methods of bone resection during surgery need to be established.
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Affiliation(s)
- Taro Miyoshi
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
| | - Mitsunobu Otsuru
- Oral and Maxillofacial Surgery, Graduate School of Kanagawa Dental University, Kanagawa, JPN
| | - Kota Morishita
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
| | - Keisuke Omori
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
| | - Kei-Ichiro Miura
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
| | - Saki Hayashida
- Dentistry and Oral Surgery, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, JPN
| | - Satoshi Rokutanda
- Dentistry and Oral and Maxillofacial Surgery, Juko Memorial Nagasaki Hospital, Nagasaki, JPN
| | | | - Masahiro Umeda
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
| | - Tomohiro Yamada
- Oral and Maxillofacial Surgery, Nagasaki University, Nagasaki, JPN
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Shin JW, Kim JE, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC. Radiological manifestations and clinical findings of patients with oncologic and osteoporotic medication-related osteonecrosis of the jaw. Sci Rep 2024; 14:8744. [PMID: 38627515 PMCID: PMC11021436 DOI: 10.1038/s41598-024-59500-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/11/2024] [Indexed: 04/19/2024] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) poses a challenging form of osteomyelitis in patients undergoing antiresorptive therapies in contrast to conventional osteomyelitis. This study aimed to compare the clinical and radiological features of MRONJ between patients receiving low-dose medications for osteoporosis and those receiving high-dose medications for oncologic purposes. The clinical, panoramic radiographic, and computed tomography data of 159 patients with MRONJ (osteoporotic group, n = 120; oncologic group, n = 39) who developed the condition after using antiresorptive medications for the management of osteoporosis or bone malignancy were analyzed. The osteoporotic group was older (75.8 vs. 60.4 years, p < 0.01) and had a longer duration of medication usage than the oncologic group (58.1 vs. 28.0 months, p < 0.01). Pus discharge and swelling were more common in the osteoporotic group (p < 0.05), whereas bone exposure was more frequent in the oncologic group (p < 0.01). The mandibular cortical index (MCI) in panoramic radiographs was higher in the osteoporotic group (p < 0.01). The mean sequestra size was larger in the oncologic group than in the osteoporotic group (15.3 vs. 10.6 mm, p < 0.05). The cured rate was significantly higher in the osteoporotic group (66.3% vs. 33.3%, p < 0.01). Oncologic MRONJ exhibited distinct clinical findings including rapid disease onset, fewer purulent signs, and lower cure rates than osteoporotic MRONJ. Radiological features such as sequestrum size on CT scan, and MCI values on panoramic radiographs, may aid in differentiating MRONJ in osteoporotic and oncologic patients.
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Affiliation(s)
- Jeong Won Shin
- Department of Orthodontics, Institute of Oral Health Science, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jo-Eun Kim
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea.
| | - Kyung-Hoe Huh
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Won-Jin Yi
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Min-Suk Heo
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Sam-Sun Lee
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Soon-Chul Choi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
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Otsuru M, Fujiki Y, Soutome S, Nakamura N, Miyoshi T, Naruse T, Ohnuma M, Hotokezaka Y, Rokutanda S, Umeda M. Risk factors for dental findings of the development of medication-related osteonecrosis of the jaw: Investigation of 3734 teeth in cancer patients receiving high dose antiresorptive agents. J Dent Sci 2024; 19:203-210. [PMID: 38303840 PMCID: PMC10829557 DOI: 10.1016/j.jds.2023.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 04/25/2023] [Indexed: 02/03/2024] Open
Abstract
Background/purpose Local infection is a risk factor for medication-related osteonecrosis of the jaw (MRONJ), along with invasive dental treatment of the bone; the tooth that is the source of infection should be extracted prior to the administration of bone resorption inhibitors. However, which teeth should be extracted remains unclear. This study aimed to determine the relationship between dental findings prior to high-dose antiresorptive agent (ARA) administration and the subsequent development of MRONJ. Materials and methods Patients with cancer who were scheduled to receive high-dose ARAs and referred to our hospital between 2011 and 2020 were included in this retrospective study. Apical lesions, enlargement of the periodontal space, thickening of the lamina dura, alveolar bone resorption of >1/3, periapical osteosclerosis, and local infection symptoms in each tooth were investigated using medical records and panoramic radiographs. Results A total of 172 patients, 329 jaws, and 3734 teeth were registered. MRONJ developed in 68 teeth in 33 jaws of 32 patients. In tooth-by-tooth analysis, fewer teeth (P < 0.001), apical lesions (P < 0.001), periapical osteosclerosis (P < 0.001), local infection symptoms (P = 0.002), and one or more dental findings (P < 0.001) were significant factors for MRONJ development. In jaw-by-jaw analysis, old age, local infection symptoms, and number of radiographic abnormalities per tooth were significant. In patient-by-patient analysis, patients with diabetes and those with fewer teeth developed MRONJ. Conclusion Patients with fewer teeth, apical lesions, periapical osteosclerosis, and local infection were more likely to develop MRONJ. Therefore, these teeth should be treated as much as possible before ARA administration.
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Affiliation(s)
- Mitsunobu Otsuru
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshinari Fujiki
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norio Nakamura
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Taro Miyoshi
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomofumi Naruse
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mizuho Ohnuma
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuka Hotokezaka
- Department of Orthodontics and Dentofacial Orthopedics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Rokutanda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Dentistry and Oral Surgery, Juko Memorial Nagasaki Hospital, Nagasaki, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Kojima Y, Sawada S, Sakamoto Y. Medication-related osteonecrosis of the lower jaw without osteolysis on computed tomography images. J Bone Miner Metab 2024; 42:27-36. [PMID: 38194089 DOI: 10.1007/s00774-023-01484-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/08/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Surgery is the standard treatment for medication-related osteonecrosis of the jaw (MRONJ). This study reviewed patients with mandibular MRONJ who underwent surgical treatment, and in particular the characteristics of non-osteolytic MRONJ with no evidence of osteolysis on CT were described. MATERIALS AND METHODS We conducted a retrospective study of patients with mandibular MRONJ who underwent surgery between January 2016 and September 2022. Various clinical and imaging factors regarding treatment outcomes were investigated and analyzed. Additionally, the disease course of non-osteolytic MRONJ was examined in detail. RESULTS This study included 55 patients (66 surgeries) with a mean age of 74.7. The primary disease was osteoporosis (24 patients) and malignancy (31 patients); the type of antiresorptive agent was bisphosphonate (BP) in 21 patients and denosumab (DMB) in 26. BP was initially administered; however, it was changed to DMB in eight patients. Preoperatively, the cumulative cure rates for all 66 surgeries were 72.8% at 1 year and 77.3% at 2 years. Cure rates were significantly lower in patients with malignancy, those without osteolysis, and those who underwent sequestrum removal or marginal mandibulectomy than those with osteoporosis, osteolysis, and segmental mandibulectomy. Non-osteolytic MRONJ was observed in eight patients, all with malignancy and receiving high-dose DMB. Only two patients were cured after the initial surgery, and most patients ultimately underwent segmental mandibulectomy. CONCLUSIONS Surgical treatment yielded good treatment outcomes in most patients with mandibular MRONJ; however, the cure rate was lower in patients with malignancy who showed no osteolysis on CT images.
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Affiliation(s)
- Yuka Kojima
- Department of Oral Surgery and Oral Care Center, Kansai Medical University Hospital, 2-3-1, Shin-Machi, Hirakata, Osaka, 573-1191, Japan.
| | - Shunsuke Sawada
- Department of Oral Surgery and Oral Care Center, Kansai Medical University Hospital, 2-3-1, Shin-Machi, Hirakata, Osaka, 573-1191, Japan
| | - Yuki Sakamoto
- Department of Oral Surgery, Kansai Medical University Medical Center, Moriguchi, Japan
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Factors Exacerbating Clinical Symptoms and CT Findings in Patients with Medication-Related Osteonecrosis of the Jaw Receiving Conservative Therapy: A Multicenter Retrospective Study of 53 Cases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137854. [PMID: 35805513 PMCID: PMC9265462 DOI: 10.3390/ijerph19137854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022]
Abstract
Recent reports have shown that better treatment outcomes are obtained with surgical therapy in patients with medication-related osteonecrosis of the jaw (MRONJ) than with conservative therapy. However, conservative treatment is selected due to factors such as old age and poor general condition. Conservative therapy aims to relieve symptoms and prevent lesion exacerbation; however, the lesion may expand rapidly in some cases. This study investigated the clinical and imaging findings of 53 MRONJ patients undergoing conservative therapy, and the changes in the clinical findings and the lesion enlargement on CT imaging were examined. Improved clinical findings and no worsening of the imaging findings were considered overall comprehensive treatment successes. Among the 53 patients, the clinical symptoms disappeared or improved in 15 patients, whereas they worsened in 6. In contrast, osteolytic lesion enlargement occurred in 17 patients. The comprehensive treatment outcome of conservative therapy was successful in 12 patients and unsuccessful in 41 patients. The periosteal reaction was significantly correlated with poor comprehensive treatment outcomes (p = 0.038). MRONJ lesions may advance, even if they appear to improve clinically while undergoing conservative treatments. Patients, especially those with periosteal reactions, must be closely followed up with CT examinations, regardless of the clinical findings.
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Otsuru M, Soutome S, Hayashida S, Yanamoto S, Sasaki M, Takagi Y, Sumi M, Umeda M. Imaging findings and treatment outcomes of a rare subtype of medication-related osteonecrosis of the jaw. J Bone Miner Metab 2022; 40:150-156. [PMID: 34510261 DOI: 10.1007/s00774-021-01267-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In our previous study, we found a rare type of medication-related osteonecrosis of the jaw (MRONJ), which shows periosteal reaction (PR) at a site distant from osteolytic lesions or the extraction site (periosteal reaction dominant type, PRd type), even though the osteolytic lesions in the bone marrow are localized. The causes and treatment of MRONJ remain unclear; hence, this study aimed to describe the imaging and clinical features of the PRd type. MATERIALS AND METHODS MRONJ patients who visited Nagasaki University Hospital between 2009 and 2020 and received conservative therapy as initial treatment were included in this study. The PR site, imaging findings, initial symptoms, outcome, and time to progression were examined. RESULTS Among 59 MRONJ patients treated with conservative therapy, 38 did not show PR (PR- type), 15 showed PR near the osteolytic region (PR + type), and 6 had the PRd type. All patients with the PRd type had submental abscesses, and computed tomography (CT) images demonstrated PR on the lingual side of the anterior mandible. Osteolytic lesions progressed in 6/6 PRd type (100%), 5/15 PR + type (33.3%), and 2/38 PR- type (5.3%) patients. Time to progression for the osteolytic region on CT was short for the PRd type, at 56-148 days (median 79 days). CONCLUSION Among the MRONJ types, the PRd type has a poor prognosis. Therefore, accumulating and analyzing more PRd cases in the future is warranted. This is the first report to describe the presence of this specific subtype of MRONJ.
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Affiliation(s)
- Mitsunobu Otsuru
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan.
| | - Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Saki Hayashida
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Souichi Yanamoto
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Miho Sasaki
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Yukinori Takagi
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Misa Sumi
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki-shi, Nagasaki-Ken, 852-8588, Japan
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Soutome S, Yanamoto S, Sumi M, Hayashida S, Kojima Y, Sawada S, Rokutanda S, Iwai H, Saito T, Umeda M. Effect of periosteal reaction in medication-related osteonecrosis of the jaw on treatment outcome after surgery. J Bone Miner Metab 2021; 39:302-310. [PMID: 33047190 DOI: 10.1007/s00774-020-01154-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/28/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Surgical treatment in patients with medication-related osteonecrosis of the jaw (MRONJ) is superior to conservative treatment. However, treatment outcome in patients with periosteal reaction (PR) was significantly poorer than that of those without PR. The purpose of this retrospective study was to analyze the pathophysiology and clinical significance of PR in MRONJ. MATERIALS AND METHODS Out of 181 patients with MRONJ undergoing surgery, 38 patients with PR were enrolled in the study. CT examinations, histological examinations, and bacteriological examinations using real-time polymerase chain reaction were performed, and the relationship among the opted surgical method, CT findings, and treatment outcome was investigated. RESULTS The pattern of PR was classified into three types: type 1, new bone is formed parallel to the mandible, and no gap was evident between the mandible and new bone; type 2, new bone is formed parallel to the mandible, and a gap was evident between them; type 3, an irregular shape. Histological examinations revealed inflammatory tissue in the area visualized as a gap on CT. Bacteriological examination showed the presence of bacteria in the type 2 or type 3 PR. Complete cure was observed in 21 of 38 (55.3%) patients, which was lower than the cure rate of 73.4% in 143 patients without PR. The cure rate was significantly lower in cases with type 3 PR or with persistent osteolysis. CONCLUSIONS It seems that complete resection of both osteolytic area and type 3 PR is necessary to obtain complete healing in patients undergoing marginal mandibulectomy.
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Affiliation(s)
- Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Souichi Yanamoto
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8588, Japan.
| | - Misa Sumi
- Department of Radiology and Cancer Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Saki Hayashida
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8588, Japan
| | - Yuka Kojima
- Department of Dentistry and Oral Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Shunsuke Sawada
- Department of Dentistry and Oral Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Satoshi Rokutanda
- Department of Dentistry and Oral Surgery, Juko Memorial Nagasaki Hospital, Nagasaki, Japan
| | - Hiroshi Iwai
- Department of Otorhinolaryngology, Head and Neck Surgery, Kansai Medical University, Osaka, Japan
| | - Toshiyuki Saito
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8588, Japan
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Wongratwanich P, Shimabukuro K, Konishi M, Nagasaki T, Ohtsuka M, Suei Y, Nakamoto T, Verdonschot RG, Kanesaki T, Sutthiprapaporn P, Kakimoto N. Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review. Dentomaxillofac Radiol 2021; 50:20200417. [PMID: 33411572 DOI: 10.1259/dmfr.20200417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with medication-related osteonecrosis of the jaw (MRONJ) often visit their dentists at advanced stages and subsequently require treatments that greatly affect quality of life. Currently, no clear diagnostic criteria exist to assess MRONJ, and the definitive diagnosis solely relies on clinical bone exposure. This ambiguity leads to a diagnostic delay, complications, and unnecessary burden. This article aims to identify imaging modalities' usage and findings of MRONJ to provide possible approaches for early detection. METHODS Literature searches were conducted using PubMed, Web of Science, Scopus, and Cochrane Library to review all diagnostic imaging modalities for MRONJ. RESULTS Panoramic radiography offers a fundamental understanding of the lesions. Imaging findings were comparable between non-exposed and exposed MRONJ, showing osteolysis, osteosclerosis, and thickened lamina dura. Mandibular cortex index Class II could be a potential early MRONJ indicator. While three-dimensional modalities, CT and CBCT, were able to show more features unique to MRONJ such as a solid type periosteal reaction, buccal predominance of cortical perforation, and bone-within-bone appearance. MRI signal intensities of vital bones are hypointense on T1WI and hyperintense on T2WI and STIR when necrotic bone shows hypointensity on all T1WI, T2WI, and STIR. Functional imaging is the most sensitive method but is usually performed in metastasis detection rather than being a diagnostic tool for early MRONJ. CONCLUSION Currently, MRONJ-specific imaging features cannot be firmly established. However, the current data are valuable as it may lead to a more efficient diagnostic procedure along with a more suitable selection of imaging modalities.
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Affiliation(s)
- Pongsapak Wongratwanich
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Kiichi Shimabukuro
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masaru Konishi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Toshikazu Nagasaki
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masahiko Ohtsuka
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Yoshikazu Suei
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Takashi Nakamoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Rinus G Verdonschot
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Tomohiko Kanesaki
- Department of Oral and Maxillofacial Surgery, Saiseikai Senri Hospital, 1 Chome-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan
| | - Pipop Sutthiprapaporn
- Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Amphur Muang, Khon Kaen 40002, Thailand
| | - Naoya Kakimoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
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Moreno-Rabié C, Gaêta-Araujo H, Oliveira-Santos C, Politis C, Jacobs R. Early imaging signs of the use of antiresorptive medication and MRONJ: a systematic review. Clin Oral Investig 2020; 24:2973-2989. [PMID: 32627123 DOI: 10.1007/s00784-020-03423-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The main aim is to identify, by means of different imaging modalities, the early bone changes in patients "at risk" and in stage 0 MRONJ. MATERIALS AND METHODS A search of the literature was performed on PubMed, Embase, Web of Science, and Cochrane Library databases, until June 9, 2020. No language or year restrictions were applied. Screening of the articles, data collection, and qualitative analysis was done. The Newcastle-Ottawa Scale (NOS) was used for observational studies, and the Systematic Review Centre for Laboratory Animal Experimentation's (SYRCLE) risk of bias tool for the animal studies. RESULTS A total of 1188 articles were found, from which 47 were considered eligible, whereas 42 were suitable for the qualitative analysis. They correspond to 39 human studies and 8 animal studies. Radiographic findings such as bone sclerosis, osteolytic areas, thickening of lamina dura, persisting alveolar socket, periapical radiolucency, thicker mandibular cortex, widening of the periodontal ligament space, periodontal bone loss, and enhancement of the mandibular canal were identified as early bone changes due to antiresorptive therapy. All those findings were also reported later in Stage 0 patients. CONCLUSION The main limitations of these results are the lack of prospective data and comparisons groups; therefore, careful interpretation should be made. It is a fact that radiographic findings are present in antiresorptive-treated patients, but the precise timepoint of occurrence, their relation to the posology, and potential risk to develop MRONJ are not clear. CLINICAL RELEVANCE The importance of a baseline radiographic diagnosis for antiresorptive-treated patients.
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Affiliation(s)
- Catalina Moreno-Rabié
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium.
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Hugo Gaêta-Araujo
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, Sao Paulo, Brazil
| | - Christiano Oliveira-Santos
- Department of Stomatology, Public Oral Health, Forensic Dentistry, Division of Oral Radiology, School of Dentistry of Ribeirao Preto, University of Sao Paulo, Sao Paulo, Brazil
| | - Constantinus Politis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Shin JW, Kim JE, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC. Clinical and panoramic radiographic features of osteomyelitis of the jaw: A comparison between antiresorptive medication-related and medication-unrelated conditions. Imaging Sci Dent 2019; 49:287-294. [PMID: 31915614 PMCID: PMC6941834 DOI: 10.5624/isd.2019.49.4.287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/03/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose This study was performed to analyze the clinical and imaging features of contemporary osteomyelitis (OM) and to investigate differences in these features on panoramic radiography according to patients' history of use of medication affecting bone metabolism. Materials and Methods The records of 364 patients (241 female and 123 male, average age 66.8±14.9 years) with OM were retrospectively reviewed. Panoramic imaging features were analyzed and compared between patients with medication-related OM (m-OM) and those with conventional, medication-unrelated OM (c-OM). Results The age of onset of OM tended to be high, with the largest number of patients experiencing onset in their 70s. The 2 most frequent presumed causes were antiresorptive medication use (44.2%) and odontogenic origin (34.6%). On panoramic radiographs, a mix of osteolysis and sclerosis was the most common lesion pattern observed (68.6%). Sequestrum, extraction socket, and periosteal new bone formation were found in 143 (42.1%), 79 (23.2%), and 24 (7.1%) cases, respectively. The m-OM group exhibited sequestrum and extraction socket more frequently and displayed significantly higher mandibular cortical index values than the c-OM group. Conclusion We observed some differences in imaging features as shown on panoramic radiography according to the history of antiresorptive medication use. This study may help elucidate the predictive imaging features of medication-related osteonecrosis of the jaw.
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Affiliation(s)
- Jeong Won Shin
- Department of Orthodontics, Institute of Oral Health Science, Ajou University School of Medicine, Suwon, Korea
| | - Jo-Eun Kim
- Department of Oral and Maxillofacial Radiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Kyung-Hoe Huh
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Won-Jin Yi
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Min-Suk Heo
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Sam-Sun Lee
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Soon-Chul Choi
- Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
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Shin JW, Kim JE, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC. Computed tomography imaging features of osteomyelitis of the jaw: comparison between antiresorptive medication-related conditions and medication-unrelated conditions. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 129:629-634. [PMID: 31983632 DOI: 10.1016/j.oooo.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to analyze and compare the imaging features of osteomyelitis according to the presence or absence of antiresorptive medications by using computed tomography (CT). STUDY DESIGN We retrospectively reviewed the records of 270 patients with osteomyelitis (83 males and 187 females; average age 66.6 years). CT imaging features were analyzed, and imaging and demographic features were compared between the medication-related osteomyelitis (MROM) group and the medication-unrelated osteomyelitis (MUOM) group. RESULTS Trabecular defects, cortical defects, sclerosis, and sequestra were detected in the majority of patients, whereas periosteal new bone formation was less common. The MROM group exhibited sequestra and periosteal new bone formation more frequently on CT images, but the size and appearance of the sequestra and type of periosteal new bone were not significantly different between the 2 groups. CONCLUSIONS Sequestra and periosteal new bone formation were characteristic CT features of osteomyelitis more commonly found in the medication-related condition. These findings may be useful in the evaluation of osteomyelitis and medication-related osteonecrosis of the jaw.
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Affiliation(s)
- Jeong Won Shin
- Clinical Assistant Professor, Department of Orthodontics, Institute of Oral Health Science, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jo-Eun Kim
- Clinical Assistant Professor, Department of Oral and Maxillofacial Radiology, Seoul National University Dental Hospital, Seoul, Republic of Korea.
| | - Kyung-Hoe Huh
- Professor, Department of Oral and Maxillofacial Radiology and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Won-Jin Yi
- Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Min-Suk Heo
- Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Sam-Sun Lee
- Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Soon-Chul Choi
- Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
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Demir A, Pekiner FN. Radiographic findings of bisphosphonate-related osteonecrosis of the jaws: Comparison with cone-beam computed tomography and panoramic radiography. Niger J Clin Pract 2019; 20:346-354. [PMID: 28256491 DOI: 10.4103/1119-3077.183241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this study is to assess radiographic findings of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and to evaluate the efficiency of cone-beam computed tomography (CBCT) and panoramic radiography (PR) by comparing with each other. MATERIALS AND METHODS The data of 46 patients treated with bisphosphonates for at least 1 to 10 years were retrospectively examined. 27 patients were selected for study group. The first inclusion criteria was an available CBCT or PR. The patients had at least one clinical symptom of exposed bone, intraoral or extraoral swelling and purulent secretion or fistula formation. In accordance with the position papers of the American Association of Oral and Maxillofacial Surgeons, the patients were classified into stages. CBCT and PR images were evaluated by dividing the jaws in 6 segments. Presence of bone sclerosis, cortex irregularity, persistent sockets, periosteal response, sequestration, and osteolysis were recorded. RESULTS The radiographic findings of BRONJ were mostly determined at posterior mandible with Stage 2 predominancy. Fifteen patients (55.6%) had previous tooth extraction. 9 of them had exposed bone at the same time. Seven patients had exposed bone without extraction. CBCT findings (P < 0.01) except persistent socket (P = 0.157) were found statistically significant by comparison with PR. Extraction socket finding was detected the same in segments with a percentage of 90.9%. CONCLUSION This study showed that CBCT findings except extraction socket were significantly higher than PR. CBCT combined with clinical examination can be used effectively to determine the borders of effected areas especially at advanced cases.
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Affiliation(s)
- A Demir
- Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Marmara University, Istanbul, Turkey
| | - F N Pekiner
- Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Marmara University, Istanbul, Turkey
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Detecting the earliest radiological signs of bisphosphonate-related osteonecrosis. Br Dent J 2017; 224:26-31. [PMID: 29192692 DOI: 10.1038/sj.bdj.2017.1001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 01/14/2023]
Abstract
Introduction Oral bisphosphonates are the most commonly prescribed anti-resorptive drugs used in the treatment of osteoporosis, but osteonecrosis of the jaw is a serious complication. The early diagnosis of this destructive side effect is crucial in preventing excessive bone loss, pain and infection.Objective To aid dental practitioners in the early identification of bisphosphonate-related osteonecrosis of the jaw.Method A scoping review was carried out.Data sources We searched MEDLINE via OVID, EMBASE via OVID, Dentistry and Oral Sciences Source (DOSS), Proquest Dissertation and Theses Search, to identify references that described clinical and radiological findings in medication-related osteonecrosis of the jaw (MRONJ).Data selection Nineteen references mentioned the earliest radiological changes in MRONJ with a description of the observations and were included in the analysis.Data synthesis The radiographic signs included osteosclerosis/lysis, widening of the periodontal ligament and thickening of the lamina dura and cortex. To assess the quality of original data on which recommendations had been made, these 19 studies were subjected to a quality appraisal.Conclusion Using bone exposure as a criterion for diagnosis of MRONJ, leads to delayed diagnosis and a poor response to treatment. In those patients at risk of bone exposure with MRONJ, insufficient information is present in the literature to allow the general dental practitioner to reliably identify the radiographic features indicating imminent bone exposure. A well-designed prospective study is needed.
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Taguchi A, Shiraki M, Morrison A, Khan AA. Antiresorptive agent-related osteonecrosis of the jaw in osteoporosis patients from Asian countries. Osteoporos Sarcopenia 2017; 3:64-74. [PMID: 30775507 PMCID: PMC6372774 DOI: 10.1016/j.afos.2017.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/05/2022] Open
Abstract
Bisphosphonate (BP)-associated osteonecrosis of the jaw (ONJ) was first reported in oncology patients in 2003 and subsequently in osteoporosis patients in 2004. Since oral surgical procedures, such as tooth extraction, are also considered one of the major risk factors for ONJ, there is confusion among physicians, dentists, and patients—particularly osteoporosis patients currently taking BPs—regarding the safety of remaining on therapy surrounding these procedures. Many papers about BP-related ONJ (BRONJ) have been published to date. In addition to BRONJ, recent studies have reported an association between ONJ and the antiresorptive therapy denosumab (Dmab; a RANKL-inhibitor). BRONJ and Dmab-related ONJ are together referred to as antiresorptive agent-related ONJ (ARONJ). The pathogenesis of ARONJ still remains unknown. It is forecasted that there will be an increased incidence of patients with osteoporotic fractures and an increased number of prescriptions for antiresorptive agents in Asia in the future. However, prescriptions for antiresorptives for osteoporosis may be restricted in the Asian population as the occurrence of ARONJ may be higher as compared with those in other countries. In this review, we focused on the following topics as it pertains to the Asian osteoporotic population: the oral condition specific for osteoporosis patients; definition, staging, prevalence and incidence of ARONJ; imaging modalities for ARONJ; specific risk factors for ARONJ; prevention strategies for ARONJ, and; cooperation between physicians and dentists in the prevention of ARONJ. Ideally, the Asian Federation of Osteoporosis Societies would cooperate with one another and find more population-specific evidence for the prevention of ARONJ.
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Affiliation(s)
- Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shiojiri, Japan
| | - Masataka Shiraki
- Research Institute and Practice for Involutional Diseases, Nagano, Japan
| | | | - Aliya A Khan
- Divisions of Endocrinology and Metabolism and Geriatrics, Department of Medicine, McMaster University, Hamilton, ON, Canada
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15
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Koth VS, Figueiredo MA, Salum FG, Cherubini K. Interrelationship of clinical, radiographic and haematological features in patients under bisphosphonate therapy. Dentomaxillofac Radiol 2017; 46:20160260. [PMID: 28107028 DOI: 10.1259/dmfr.20160260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To analyze the clinical, radiographic and haematological aspects of patients under bisphosphonate therapy. METHODS A retrospective study was conducted where the records of patients taking bisphosphonates were analyzed considering the occurrence of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Evaluation included panoramic and periapical radiographies, haematological examinations and clinical features. Radiographies were analyzed determining the presence or absence of bone sclerosis, osteolysis, persisting alveolar socket, narrowing of the mandibular canal, widening of the periodontal ligament space, periradicular radiolucency, sequestrum and thickening of the lamina dura. Laboratory tests consisted of complete blood count, fasting serum glucose, erythrocyte sedimentation rate (ESR) and serum levels of calcium, phosphorus, alkaline phosphatase, parathormone (PTH) and C-terminal telopeptide of collagen I (CTX). RESULTS Alkaline phosphatase and ESR were significantly higher in the BRONJ group, whereas fasting serum glucose, CTX, PTH, calcium and phosphorus did not significantly differ. BRONJ showed association with smoking, tooth extraction, anaemia and leukocytosis. On radiographic analysis, persisting alveolar socket, osteolysis, bone sclerosis and narrowing of the mandibular canal were significantly more prevalent in the BRONJ group. Thickening of the lamina dura, periapical radiolucencies, widening of the periodontal ligament space and sequestrum did not significantly differ between the groups. CONCLUSIONS BRONJ is a multifactorial disease with high morbidity, which requires experimental studies to clarify the role of the reported risk factors and clinical radiographic signs to improve its diagnosis.
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Affiliation(s)
- Valesca S Koth
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria A Figueiredo
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda G Salum
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Karen Cherubini
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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Khan AA, Morrison A, Kendler DL, Rizzoli R, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Dabagh RA, Davison KS, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ. J Clin Densitom 2017; 20:8-24. [PMID: 27956123 DOI: 10.1016/j.jocd.2016.09.005] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada.
| | - Archie Morrison
- Division of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, NS, Canada
| | - David L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - David A Hanley
- Departments of Medicine, Community Health Sciences and Oncology, University of Calgary, Calgary, AB, Canada
| | - Dieter Felsenberg
- Centre of Muscle & Bone Research, Charité-University Medicine Berlin, Campus Benjamin Franklin, Free University & Humboldt University Berlin, Berlin, Germany
| | - Laurie K McCauley
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA
| | - Felice O'Ryan
- Division of Maxillofacial Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA; Stony Brook School of Dental Medicine, Stony Brook, NY, USA; New York Center for Orthognathic and Maxillofacial Surgery, New York, NY, USA
| | - Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shojiri, Japan
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Edmund Peters
- Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Teresa Guise
- Department of Medicine, Division of Endocrinology at Indiana University, Indianapolis, IN, USA
| | - Richard Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging, University Health Network (UHN), Toronto, ON, Canada; Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Basel Masri
- Jordan Osteoporosis Center, Jordan Hospital & Medical Center, Amman, Jordan
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Birmingham, AL, USA
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rana Al Dabagh
- Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - K Shawn Davison
- Department of Education, University of Victoria,Victoria, BC, Canada
| | - George K Sándor
- Department of Oral and Maxillofacial Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Robert G Josse
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | | | - Riad Sulimani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Deborah P Saunders
- Department of Dental Oncology, Northeast Cancer Centre/Health Science North, Sudbury, ON, Canada
| | - Jacques P Brown
- Rheumatology Division, CHU de Québec Research Centre, Laval University, Quebec City, QC, Canada
| | - Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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17
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Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015; 30:3-23. [PMID: 25414052 DOI: 10.1002/jbmr.2405] [Citation(s) in RCA: 822] [Impact Index Per Article: 91.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/03/2014] [Accepted: 11/05/2014] [Indexed: 11/08/2022]
Abstract
This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.
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Zaman MU, Nakamoto T, Tanimoto K. A retrospective study of digital subtraction technique to detect sclerotic changes in alveolar bone on intraoral radiographs of bisphosphonate-treated patients. Dentomaxillofac Radiol 2013; 42:20130242. [PMID: 24170801 DOI: 10.1259/dmfr.20130242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Several reports have suggested that sclerotic changes in cancellous bone of the jaw and thickening of the lamina dura are characteristic radiographic changes of an early silent stage of bisphosphonate (BP)-related osteonecrosis of the jaw. No quantitative evaluation has been reported to support this hypothesis. Emago(®) software (Oral Diagnostic Systems, Amsterdam, Netherlands) can perform digital subtraction on intraoral radiographs even if they were obtained by non-standardized radiography, provided the dimensional error is within a certain limit. The purpose of this study was to evaluate whether sclerotic changes of alveolar bone or thickening of lamina dura in patients using BP can be detected using the subtraction function of Emago. METHODS The authors selected 46 pairs of intraoral radiographs of the mandibular molar area in dental patients. All radiographs were obtained at intervals of 6 months or more. Among the 46 pairs, 7 pairs were from patients who were being treated with BP (study subjects), and 39 pairs were from patients who had not been using BP (controls). All pairs of radiographs underwent digital subtraction by Emago. The number of pixels of the sclerotic areas was counted and compared between subjects and controls. RESULTS The sclerotic changes were significantly distinguishable in two of the seven subjects (28.6%) using BP. CONCLUSIONS Digital subtraction function of Emago was able to detect sclerotic changes in alveolar bone. Therefore, it is suggested that the subtraction function of Emago is a useful tool for quantitatively detecting sclerotic changes that are observed at an early, silent stage of BP-related osteonecrosis of the jaw.
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Affiliation(s)
- M U Zaman
- Department of Oral and Maxillofacial Radiology, Division of Medical Intelligence and Informatics, Graduate School of Biomedical Science, Hiroshima University, Hiroshima, Japan
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