Autologous platelet concentrates for bisphosphonate-related osteonecrosis of the jaw treatment and prevention. A systematic review of the literature

Autologous platelet concentrates as adjuvant in the surgical management of medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw (MRONJ) is an infectious side effect associated with bisphosphonates and monoclonal antibodies (denosumab, immune modulators, and antiangiogenic medications). Adjunctive therapies for the surgical management of MRONJ include autologous platelet concentrates (APCs). These APCs serve as a source of various cells and growth factors that aid tissue healing and regeneration. This review evaluated the use of platelet-rich plasma (PRP), plasma-rich in growth factors (PRGF), and leukocyte- and platelet-rich fibrin (L-PRF) as adjuvant therapies for the surgical management of MRONJ by conducting analyses on the results of 58 articles. Compared to surgical treatment alone, the application of PRP and L-PRF after surgery appears to increase healing in the management of patients with MRONJ. No studies have reported unhealed lesions as a result of surgical treatment of MRONJ with PRGF application or compared it with surgical treatment alone. The overall results of this review have shown favorable healing rates of MRONJ lesions managed with the application of APCs after surgical treatment; however, significant methodological limitations may limit the scientific evidence supporting their use. Further randomized controlled trials with strict criteria are needed to establish the extent to which APCs can improve wound healing and quality of life in patients with MRONJ requiring surgical treatment.

Platelet-Rich Plasma in the Prevention and Treatment of Medication-Related Osteonecrosis of the Jaw: A Systematic Review and Meta-Analysis

OBJECTIVES

Medication-related osteonecrosis of the jaw (MRONJ) is a significant complication associated with bisphosphonates, impacting jaw osteoclasts, and causing altered bone remodelling. Prevention involves stabilizing systemic pathology, considering antiresorptive therapies, and exploring platelet-rich fibrin (PRF) for wound healing and tissue regeneration. The study aims to assess the efficacy of PRF in MRONJ treatment and highlight research gaps for more robust investigations.

METHODS

Following PRISMA and MOOSE guidelines, this systematic review and meta-analysis included English publications from 2013 to 2023, employing a systematic search in databases such as MEDLINE, Scopus, and Web of Science. Quality assessment used the Cochrane Collaboration's tool and the NOS, with the main meta-analysis concentrating on PRF-treated MRONJ cases, assessing resolution rates, and prioritizing healing outcomes and infection absence as primary endpoints.

RESULTS

The study, encompassing 11 articles and 480 participants with MRONJ, demonstrated that in stage 1 procedures, PRF significantly outperformed conventional medical treatments (OR: 2.93, 95% CI: 1.54-5.59, P=0.001), particularly at the mandible site (OR: 1.65, 95% CI: 0.86-3.17, P=0.13). PRF also exhibited significantly superior healing outcomes compared with conventional medical treatments (OR: 4.45, 95% CI: 1.58-12.53, P=0.005), supporting its consideration as a valuable alternative in specific MRONJ management scenarios.

CONCLUSION

This study highlights PRF's effectiveness in early MRONJ interventions and specific anatomic sites, despite acknowledged limitations, emphasizing the need for further research, and supporting its consideration in MRONJ surgical management.

Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ)

OBJECTIVE

This paper aims to describe the 2023 update position paper on MRONJ developed by the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Maxillofacial Surgery (SICMF).

METHODS

This is the second update following the 2013 and 2020 Italian position papers by the Expert panel, which is a representation of the two scientific societies (SIPMO and SICMF). The paper is based on an extensive analysis of the available literature from January 2003 to February 2020, and the subsequent review of literature conducted between March 2020 and December 2022 to include all new relevant published papers to confirm or modify the previous set of recommendations.

RESULTS

This position paper highlights the main issues of MRONJ on risk estimates, disease definition, diagnostic pathway, individual risk assessment, and the fundamental role of imaging in the diagnosis, classification, and management of MRONJ.

CONCLUSION

The Expert Panel confirmed the MRONJ definition, the diagnostic work-up, the clinical-radiological staging system and the prophylactic drug holiday, as recognized by SIPMO-SICMF; while, it presented novel indications regarding the categories at risk of MRONJ, the prevention strategies, and the treatment strategies associated with the therapeutic drug holiday.

Clinical Performance of Implant-Supported Prostheses in the Rehabilitation of Patients Previously Treated for Medication-Related Osteonecrosis of the Jaws (MRONJ): A Systematic Review

There is a lack of consensus on managing resultant bone and soft tissue defects or on restoring oral function and aesthetics following medication-related osteonecrosis of the jaws (MRONJ) lesion healing. This clinical challenge presents a dilemma for practitioners. Removable prostheses pose a recurrence risk if poorly fitted and may inadequately restore function or aesthetics in cases of significant bone defect. Dental implant-supported prostheses could enhance function and quality of life, though their risks and indications are not well-defined. This systematic review examines the clinical outcomes and complications associated with implant-supported rehabilitations post-MRONJ surgery. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations and it was pre-registered in the Prospective Register of Systematic Reviews (PROSPERO) (CRD42023492539).

The role of leukocyte and platelet-rich fibrin in the prevention of medication-related osteonecrosis of the jaw, in patients requiring dental extractions: an observational study

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) is a significant complication which can present following a dental extraction in patients receiving anti-resorptive and anti-angiogenic medications. The purpose of this study was to investigate the possible beneficial effect of L-PRF in the prevention of MRONJ in patients receiving these medications and requiring dental extractions.

METHODS

Thirty-nine patients were included and divided into two groups, depending on whether L-PRF was used after the required dental extraction or not. Subsequently, the patients were categorised into low and high-risk for developing MRONJ, as recommended by the SDCEP guidance.

RESULTS

None of the patients in the L-PRF group returned with established MRONJ. Five high-risk patients in the control group presented with established MRONJ in the follow-up appointment. A significant statistical difference (p = 0.04) was observed following a comparison of the high-risk patients of the two groups.

CONCLUSION

These encouraging results suggest that L-PRF may be useful in the prevention of MRONJ following a dental extraction especially in patients of the higher risk category. A protocol for the management of this type of patients is also introduced.

How does the clinical and tomographic appearance of MRONJ influences its treatment prognosis?

OBJECTIVES

To identify clinical and tomographic prognostic factors for conservative and surgical treatment of medication-related osteonecrosis of the jaws (MRONJ).

METHODS

A retrospective search identified patients treated with antiresorptive drugs (ARDs), diagnosed with Stage 1, 2 or 3 MRONJ, and having CBCT scans previous to conservative or surgical treatment. Following data collection, imaging assessment of the following parameters on each MRONJ site was performed: involvement of teeth and/or implants, presence of osteosclerosis, osteolysis, sequestrum formation, periosteal reaction, and pathological fractures. For statistical analysis, patients and lesions were divided into conservative and surgical treatment. Comparisons were made between successful and unsuccessful outcomes. Significance was set at p ≤ 0.05.

RESULTS

115 ARD-treated patients who developed 143 osteonecrosis lesions were selected. 40 patients and 58 lesions received conservative treatment, of which 14 patients (35%) and 25 lesions (43%) healed. Additionally, 75 patients and 85 lesions underwent surgery, with 48 patients (64%) and 55 lesions (65%) that healed. Clinical and tomographic risk factors for conservative treatment were MRONJ staging, tooth involvement, extensive osteosclerosis, and deep sequestrum formation (p < 0.05). Complementarily, poor prognostic indicators for surgical therapy were a short bisphosphonate (BP) holiday, MRONJ staging, absence of sequestrum formation, and presence of periosteal reaction (p < 0.05).

CONCLUSIONS

Lesions at Stage 3 MRONJ, with tooth involvement, or sequestrum formation showed poor outcomes when conservative treatment is chosen. Alternatively, surgical treatment is most effective when BPs are discontinued, in Stage 1 lesions, in the presence of sequestrum formation, and absence of periosteal reaction.

Prevention and management of drug-induced osteonecrosis of the jaws using platelet-rich fibrin: A clinical feasibility study

OBJECTIVE

Although a standard treatment guideline has not been established to date, various treatment modalities have been described in the literature based on the staging of medication-related osteonecrosis of the jaw (MRONJ). The aim of this case series was to describe the outcomes of surgical intervention of MRONJ cases with the adjunctive use of platelet-rich fibrin (PRF).

MATERIALS AND METHODS

Thirteen patients under therapy with zoledronic acid, seven of them underwent surgical removal of necrotic bone with debridement, followed by placement of three to four PRF membranes and achieving primary closure. In six patients, PRF was used preventively to avoid MRONJ.

RESULTS

The surgical treatment outcomes were successful in all patients, with a follow-up range of 12-48 months. In the presented cases, the intraoral evaluation showed excellent soft tissue healing except for one patient secondary wound healing was reported. Additionally, there was no recurrence of bone exposure in all cases. PRF membranes were comparatively effective in postsurgical pain control.

CONCLUSION

The use of PRF could represent a valuable adjunct in the surgical management for advanced stages of MRONJ cases.

CLINICAL RELEVANCE

This clinical case series describes the use of PRF membranes as a valuable adjunct in the surgical management of MRONJ patients, especially when treating advanced MRONJ cases. Moreover, PRF demonstrates usefulness in preventing such difficult complications from occurring.

Histopathological assessment of the preventive effect of leukocyte-platelet-rich fibrin on bisphosphonate-related osteonecrosis of the jaw following dental extraction: An animal study

Background

Leukocyte- and platelet-rich fibrin (L-PRF) could be considered a preventive measure in Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ). The present experiment aimed to assess the preventive effects of L-PRF on osteonecrosis of the jaw in rats.

Methods

In this interventional animal study with a split-mouth design, 28 rats were randomly allocated to saline (negative control), bisphosphonate (positive control), and Bis + L-PRF (case) groups. Bilateral extraction of maxillary molar teeth was performed followed by random application of L-PRF to one of the extraction sockets treated with Zoledronic acid for four weeks. Clinical occurrence of BRONJ and histopathologic evaluations were done, and data were subjected to the Kruskal-Wallis test, Mann-Whitney U test and exact Fisher test performed using SPSS 25. The significance level was set at 0.05.

Results

The application of L-PRF resulted in a 41.67% reduction in osteonecrosis centers and the number of osteoclast cells. Also, Kruskal Wallis test results showed a significant difference among the three groups regarding the frequency distribution of inflammation severity. However, no significant difference was detected regarding the frequency distribution of the blood vessels (Kruskal Wallis test, P-value = 0.649).

Conclusion

It could be inferred that possible preventive effects on the clinical occurrence of osteonecrosis could be expected from the application of L-PRF.

Laser Devices and Autologous Platelet Concentrates in Prevention and Treatment of Medication-Related Osteonecrosis of the Jaws: A Systematic Review

Background and Objectives: Medication-related osteonecrosis of the jaws (MRONJ) is a disease that affects many patients taking anti-angiogenic and antiresorptive medicines. Since the pathogenetic mechanism is still partially unknown, preventive strategies, as well as treatment alternatives, are needed. Therefore, the aim of this research is to describe the main evidence from the last 10 years of clinical trials regarding the use of auxiliary devices such as autologous platelet concentrates (APCs) and laser, other than their effects against MRONJ disease onset or therapy. Advantages in the healing process and recurrence rates were also analyzed. Materials and Methods: A systematic search of the electronic databases of PubMed and Scopus was carried out. Data from the studies were analyzed, and the risk of bias was evaluated. Results: Nineteen studies between interventional studies, observational studies, and cohort studies have been considered in this review. Conclusions: Based on the studies included, the literature analysis shows that APCs could be a beneficial alternative in preventing and treating MRONJ. Laser technology, as a surgical tool or used on the antimicrobial photodynamic or photobiomodulation side, has been becoming increasingly popular in the last few years. The latest proposal concerning the combination of both auxiliary tools suggests interesting effects, but more studies should be conducted to evaluate eventual relapses and long-term consequences.

Management of Tooth Extraction in Patients Taking Antiresorptive Drugs: An Evidence Mapping Review and Meta-Analysis

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known severe adverse reaction of antiresorptive, antiangiogenic or targeted therapies, and usually occurs after tooth extraction. This review is aimed at determining the efficacy of any intervention of tooth extraction to reduce the risk of MRONJ in patients taking antiresorptive drugs, and present the distribution of evidence in these clinical questions.

METHODS

Primary studies and reviews were searched from nine databases (Medline, EMBase, Cochrane Library, Scopus, WOSCC, Inspec, KCI-KJD, SciELO and GIM) and two registers (ICTRP and ClinicalTrials.gov) to 30 November 2022. The risk of bias was assessed with the ROBIS tool in reviews, and the RoB 2 tool and ROBINS-I tool in primary studies. Data were extracted and then a meta-analysis was undertaken between primary studies where appropriate.

RESULTS

Fifteen primary studies and five reviews were included in this evidence mapping. One review was at low risk of bias, and one randomized controlled trial was at moderate risk, while the other eighteen studies were at high, serious or critical risk. Results of syntheses: (1) there was no significant risk difference found between drug holiday and drug continuation except for a subgroup in which drug continuation was supported in the reduced incidence proportion of MRONJ for over a 3-month follow-up; (2) the efficacy of the application of autologous platelet concentrates in tooth extraction was uncertain; (3) there was no significant difference found between different surgical techniques in any subgroup analysis; and (4) the risk difference with antibacterial prophylaxis versus control was -0.57, 95% CI -0.85 to -0.29.

CONCLUSIONS

There is limited evidence to demonstrate that a drug holiday is unnecessary (and may in fact be potentially harmful) in dental practice. Primary closure and antibacterial prophylaxis are recommended despite limited evidences. All evidence have been graded as either of a low or very low quality, and thus further high-quality randomized controlled trials are needed to answer this clinical question.

The combined use of photobiomodulation therapy and platelet-rich fibrin for the management of two MRONJ stage II cases: An alternative approach

Medication-related osteonecrosis of the jaws (MRONJ) is a relatively rare but serious adverse drug reaction in patients under bone-targeting or antiangiogenic medication for malignant or osteometabolic diseases. The pathogenesis of MRONJ is multifactorial with the inhibition of osteoclasts and angiogenesis considered to play a keyrole in an individually susceptible environment, thus its prevalence is highly differentiated according to each study. Even though MRONJ has been reported since 2003 and the literature is expanding rapidly about possible risk factors, prevention and treatment options, the successful management with no recurrence is still under controversy. The conservative non-surgical (optimal oral hygiene, systemic antibiotic therapy) and surgical procedures (debridement, sequestrectomy or bone resection) are considered the treatment of choice especially at the early stages. Adjuvant therapies have been proposed to further stimulate bone and tissue healing such as teriparatide, bone morphogenic proteins, platelet concentrates, hyperbaric oxygen, ozone therapy, photodynamic therapy and lasers with promising results. The need to develop minimally invasive treatment protocols using novel technologies in particular for those patients with severe medical history has been highlighted in the literature. The clinical protocol that has been developed in our dental department, which is effectively contributing to MRONJ management and associates Photobiomodulation therapy (PBMT) with platelet-rich fibrin (A-PRF), will be presented in this article.

Bone-Regenerative Ability of Platelet-Rich Plasma Following Sinus Augmentation with Anorganic Bovine Bone: A Systematic Review with Meta-Analysis

BACKGROUND

The objective of this systematic review is to assess the effect of the adjuvant use of platelet-rich plasma (PRP) and its type on new bone formation by anorganic bovine bone during maxillary sinus floor augmentation procedure.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and Ovid databases were searched for relevant studies published up to 16 September 2021. Randomized clinical trials (RCTs) and non-randomized controlled clinical trials (CCTs) that reported data on the new bone formation (measured by histomorphometric analysis) were considered. Risk of bias and quality assessment of included studies were evaluated following the Cochrane Handbook for Systematic Reviews of Interventions and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Strength of evidence was assessed following the approach of the Agency for Healthcare Research and Quality (AHRQ) through its evidence-based practice center (AHRQ EPC). The meta-analysis was based on the primary outcome of newly formed bone, for which the standard mean difference was calculated.

RESULTS

After the application of eligibility criteria, six clinical trials (three RCTs and three CCTs) covering 85 maxillary sinus floor elevation procedures were included. The pooled new bone formation value for PRP was 1.67 (95% CI: -0.15 to 3.49; I2: 86%), indicating the absence of significant effect. Plasma rich in growth factors (PRGF) was the pure PRP tested in five of the included studies. When sub-group (type of PRP) meta-analysis was performed, significantly higher new bone formation was observed in the PRGF group [2.85 (95% CI: 0.07 to 5.64; I2: 88%)] in comparison to the control group.

CONCLUSIONS

A beneficial effect on new bone formation after maxillary sinus floor elevation can be obtained when anorganic bovine bone is mixed with PRGF.

Autologous Platelet Concentrates (APCs) for Hard Tissue Regeneration in Oral Implantology, Sinus Floor Elevation, Peri-Implantitis, Socket Preservation, and Medication-Related Osteonecrosis of the Jaw (MRONJ): A Literature Review

Simple Summary

Autologous platelet concentrates with high growth factor levels are used in many fields of dentistry. In recent years, the critical role of blood-derived materials in bone and soft tissue engineering has become apparent. After tooth extraction, the alveolar bone is exposed to progressive bone resorption, which can lead to difficulties in implant placement. Hence, many studies have demonstrated that APCs have the potential for soft tissue and bone regeneration. Furthermore, no inflammatory reactions occur, and they may be used alone or in combination with bone grafts, promoting bone growth and maturation. Moreover, the released growth factors and the presence of fibrin structures can induce osteogenesis. This review aims to provide information regarding the applications, indications, advantages, and disadvantages of three APC techniques in hard tissue regeneration.

Abstract

Over recent years, the usage of autologous platelet concentrates (APCs) has risen in hard tissue regeneration and oral implantology. The purpose of the present review is to offer an overview of the use of three APC techniques in dentistry: platelet-rich plasma (PRP), platelet-rich fibrin (PRF), and concentrated growth factor (CGF). A narrative summary of articles published between January 2011 and April 2022 is provided. The PubMed, Cochrane Library, Scopus, and Embase databases were used to conduct the search. The following keywords were used in the preliminary: “VEGF”, “TGF-b1”, “PRP”, “PRF”, “CGF”, AND “sinus augmentation” OR “implants” OR “peri-implantitis” OR “socket preservation” OR “MRONJ”. A total of 82 articles was finally included. The review then takes into account the application of the three techniques in different areas of treatment—including oral implantology, sinus floor elevation, peri-implantitis, socket preservation, and medication-related osteonecrosis of the jaw (MRONJ)—as well as their advantages and disadvantages.

Non-Interventional Prospective Observational Study of Platelet Rich Fibrin as a Therapy Adjunctive in Patients with Medication-Related Osteonecrosis of the Jaw

BACKGROUND

Medication-related osteonecrosis (MRONJ) of the jaw is a severe and feared side effect of antiresorptive therapy in the oncological setting. With growing evidence that impaired angiogenesis may represent a key factor in pathogenesis, the aim of this study was to evaluate an autologous platelet concentrate as a possible additive in surgical therapy to optimize vascularization and, subsequently, resolution rates.

MATERIAL AND METHODS

A non-interventional, prospective, multicenter study was conducted, and all patients with stage I-III MRONJ, undergoing antiresorptive therapy for an oncological indication, were included. The necrosis was treated surgically without (study arm A) or with (arm B) the addition of an autologous platelet concentrate (platelet-rich fibrin, PRF).

RESULTS

After 5, 14, and 42 days postoperative, wound healing (primary outcome: mucosal integrity) as well as downstaging, pain perception, and oral health-related quality of life (secondary outcome) were assessed via clinical evaluation. Among the 52 patients included, primarily with MRONJ stage I and II, the use of PRF as an additive in surgical therapy did not display a significant advantage for wound healing (p = 0.302), downstaging (p = 0.9), pain reduction (p = 0.169), or quality of life (p = 0.9).

SUMMARY

In conclusion, PRF as an adjunct did not significantly optimize wound healing. Further, no significant changes in terms of downstaging, pain sensation, and oral health-related quality of life were found.

[Bisphosphonate-related osteonecrosis of the jaws]

The number of patients with metabolic osteopathies and oncological diseases occurring with the formation of bone metastases is constantly growing and requires special attention not only of oncologists, but also maxillofacial surgeons, dental surgeons and periodontists, due to severe complications from the oral cavity, against the background of antiresorptive therapy with bisphosphonates. These drugs are associated with the development of necrotic processes of the jaw bones and surrounding tissues. It is worth noting the fact that the development of complications after taking these drugs leads to a significant increase in the suffering of patients. The importance of an integrated approach to the treatment and prevention of such complications is extremely important, as it reduces the risk of possible complications and improves the quality of life of this group of patients.

Medication related osteonecrosis of the jaws (MRONJ): Factors related to recurrence after treatment with surgery and platelet rich plasma (PRP) placement

Background

Medication-related osteonecrosis of the jaws (MRONJ) is a well-known complication associated with antiresorptive and antiangiogenic therapies. The purpose of this study was to analyse if there is any predictive factor of recurrence after local debridement plus platelet rich plasma (PRP) placement in MRONJ patients.

Material and Methods

Seventy MRONJ patients treated at the department of Oral and Maxillofacial Surgery in La Paz Hospital (Madrid, Spain) were included in this retrospective study. All of them were treated surgically by local debridement and PRP placement. The observation period was between January 2012 and January 2019. Information regarding use, type, administration, and duration of therapy with BP/denosumab was recorded. The follow-up period ranged from 2-52 months. A descriptive analysis, a bivariate and a multivariate study were performed.

Results

Most of the patients were women (82.9%) between 50-70 years old (64.3%), with a stage II disease (74.3%). The therapy lasted more than 12 months in 54.8% of them. Zoledronic acid was the main antiresorptive used (44.3%), followed by oral administered BPs (29 patients, 41.4%) and denosumab (10 patients, 14.3%). Osteoporosis (48.6%), breast cancer (30%) and multiple myeloma (11.4%) were the main diseases because the patients were taking antirresorptives. 13 patients (18.6%) experienced recurrence. We found that breast cancer patients (p>0.0001), smokers (p>0.016), and administration of zoledronic acid (p>0.0001) were related to recurrence. After performing the multivariate model, we found that the only factor related to recurrence was smoking habit (Wald 3.837, p=0.05, OR 6.12).

Conclusions

recurrence after local debridement plus PRP placement in our MRONJ series affected to 18.6% of patients. It seems to be more frequent in breast cancer patients, smokers, and after zoledronic acid administration. Smoking habit was the only independent factor related to recurrence in our series.

Key words:Osteonecrosis of the jaw, recurrence, risk factor, bisphosphonates, zoledronic acid, denosumab, platelet rich plasma.

Surgical vs conservative treatment of medication-related osteonecrosis of the jaw-A complex systematic review and meta-analysis

OBJECTIVE

The objective of this study was to compare the outcome of surgical and conservative treatment approaches for medication-related osteonecrosis of the jaw.

STUDY DESIGN

Publications in Medline, The Cochrane Library, EMBASE, and PubMed (non-indexed articles) and by Health Technology Assessment organizations were searched. Quality of evidence in primary studies were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the level of bias in systematic reviews by a measurement tool to assess systematic reviews (AMSTAR).

RESULTS

Quality assessment identified 3 primary studies with moderate GRADE score. Moderate risk of bias was found in 7 systematic reviews and low risk of bias in 3. Nine studies were included in the meta-analysis, where 62.1% healing was reported after surgical treatment (144 of 232 included patients) and 28.8% healing was reported after conservative treatment (38 of 132 included patients). Moderate heterogeneity was found among the included studies (P = .02). The overall odds ratio for resolution of osteonecrosis after surgical versus conservative treatment was 1.25 (95% confidence interval, 0.24-2.26) and was not statistically significant.

CONCLUSION

Slightly better outcomes are reported after surgical treatment, in particular for advanced disease stages, but there is a lack of standardized treatment protocols and outcome measures. Overall, the quality of evidence is poor, and the majority of studies have a low evidence certainty rating and high risk of bias.

Autologous Platelet Gel (APG): A Preliminary Evaluation of the Mechanical Properties after Activation with Autologous Thrombin and Calcium Chloride

The tensional and mechanical behavior of regenerative components, grafts, and blood clots represent an essential condition for the success of bone regeneration protocols. Autologous platelet growth factors represent a useful protocol to enhance the soft and hard tissue healing in several fields of medicine and craniofacial surgery. Different protocols for blood concentrates with and without activation have been proposed in literature. The aim of the present study was to investigate in vitro the mechanical properties of autologous platelet gel (APG) with autologous thrombin and calcium chloride. Materials and Methods: A total of 20 APG samples were evaluated; 10 samples were activated by autologous thrombin and calcium chloride (Group I) and 10 samples were non-activated (Group II). The tensile strength and modulus of elasticity were calculated through a static loading test (Lloyd 30 K, Lloyd Instruments Ltd., Segensworth, UK). Results: Group I (activated) reported a tensile strength of 373.5 ± 14.3 MPa, while Group II showed a significantly lower value of 360.5 ± 16.3 MPa (p < 0.05). The Young’s modulus was 145.3 ± 10.4 MPa for Group I and 140.3 ± 15.3 MPa for Group II (p < 0.05). Conclusions: The effectiveness of the present in vitro simulation showed that the APG activation protocol is able to increase the mechanical characteristics of the blood derivates and could be clinically useful to enhance regenerative procedures.

The Role of Autologous Platelet Concentrates in the Treatment of Medication-Related Osteonecrosis of the Jaw

ABSTRACT

The frequent refractory response of patients to the treatment of medication-related osteonecrosis of the jaw (MRJON) has attracted clinicians' attention to several treatments. However, they are at best, palliative, and have a higher failure rate than previous treatments. The present meta-analysis was performed to evaluate the clinical effectiveness of autologous platelet concentrates (APCs) combined with surgery in the treatment of MRONJ. The authors conducted a meta-analysis involving a systematic search of PubMed, EMBASE, Wiley Online Library and the Cochrane Library for eligible studies from their inception to November 2019, in accordance with preselected criteria. The inverse variance method was applied to fixed or random effects models based on the heterogeneity of the studies. Thirteen studies that investigated APCs in the treatment of MRONJ were eligible for inclusion in the meta-analysis of 223 patients and 33 lesions. The pooled success rate of APCs combined with surgery for MRONJ was 90% (95%CI, 80%-97%) and the pooled OR was 7.67 (95%CI, 2.10-27.98), indicating the combination was 7.67 times more effective than surgery alone. The results suggest that the use of APCs is a promising therapeutic regimen, as it provided additional benefits to surgery in the treatment of MRONJ. To achieve the benefits, a tension-free primary closure of the soft tissue is recommended as well. Randomized studies with large sample sizes is warranted to confirm our finding.

Dental Implants with a Calcium Ions-Modified Surface and Platelet Concentrates for the Rehabilitation of Medically Compromised Patients: A Retrospective Study with 5-Year Follow-Up

Background: Platelet concentrates are biological, autologous products obtained from the patient’s whole blood, consisting of a supraphysiological concentration of platelets and growth factors, that have proved beneficial in different applications in the medical and dental fields. They are used in several medical and dental applications to enhance tissue healing. Previous evidence shows that platelet concentrates may be beneficial in patients with compromised systemic conditions, in which the healing process is impaired. Aim: To evaluate the 5-year clinical outcome of implant treatment using acid-etched implants with calcium ions-modified surface in association with plasma rich in growth factors, in patients with systemic diseases of a different nature. Methods: Charts of 99 medically compromised patients, who had received a total of 224 dental implants from January 2013 to June 2013, were retrospectively evaluated. Patients were divided into four groups, according to their condition: diabetes (n = 39 patients), osteoporosis (n = 36), lupus erythematosus systemic (n = 5), rheumatoid arthritis (n = 19). The main outcomes were implant survival, marginal bone level (MBL) change and complications throughout follow-up. Results: Mean follow-up was 63.06 ± 1.90 months (range 60.1 to 66.4 months). In total, eight implants failed in 6 diabetic patients and 4 in 3 patients with rheumatoid arthritis. Overall 5-year implant survival was 94.6%. In total, 30 complications occurred in 24 patients, mostly transient, and no severe adverse event occurred. Overall MBL change was 0.45 ± 0.12 mm, with no significant differences among groups. Conclusions: In the present sample of medically compromised patients, rehabilitation with calcium ions-modified surface implants associated with plasma rich in growth factors proved to be a safe and effective treatment. The satisfactory results achieved after 5-year follow-up are comparable to those historically reported for healthy patients.

The Role of Platelet-Rich Fibrin (PRF) in the Prevention of Medication-Related Osteonecrosis of the Jaw (MRONJ)

Dentoalveolar surgery is probably the major risk factor for MRONJ and for other complications following a tooth extraction, especially in patients affected by systemic diseases. The aim of this retrospective study is to evaluate whether a PRF plug inserted in the post extraction socket can prevent the onset of MRONJ. The patients were divided into two groups according to the surgical protocol that included the insertion or not of the PRF following the extraction and all the anamnestic, and clinical data were analyzed. In the control group, 5 patients developed MRONJ (19.23%) while in the study group, any case of MRONJ was reported. In the control group, patients who developed MRONJ had a CTX with less than 100 pg/mL (5 high-risk patients, Spearman's rank r = .547, p < .001). The use of platelet concentrates in patients with high risk of MRONJ is a user-friendly technique with an excellent cost-benefit ratio in oral surgery.

Autologous Platelet-Rich Fibrin (PRF) as an Adjunct in the Management of Osteoradionecrosis and Medication-Related Osteonecrosis of Jaws. Case Series in A Single Centre

Osteoradionecrosis (ORN) of the jaws and medication-related osteonecrosis of the jaws (MRONJ) are uncommon but serious diseases affecting the oral and maxillofacial region with clinically similar appearance but distinct pathophysiology. Management of ORN and MRONJ is inherently challenging and the treatment outcomes are unpredictable. The use of autologous platelet concentrates (APCs) to promote hard and soft tissue healing is well described in the literature, and the efficacy of leucocyte and platelet-rich fibrin (L-PRF) has been well documented in a number of clinical studies. The aim of this study was to present our treatment strategy and the outcomes of incorporating L-PRF as a surgical adjunct in management of ORN and MRONJ in our centre. Methods: eight cases of ORN and MRONJ were treated with a combination of sequestrectomy and L-PRF as a surgical adjunct. Results: the overall success was 87.5%. Using L-PRF as an adjunct, we were able to predictably manage ORN and MRONJ without causing significant morbidity. Conclusion: our experience shows that L-PRF may be used as a valuable and cost-effective adjunct to surgical management of ORN and MRONJ. However, due to a limited number of patients, and a short period of review, the true effectiveness of the method is yet to be demonstrated in a longer follow-up study including a greater number of patients, besides the inclusion of a control group.

The effect of concentrated growth factor (CGF) in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: a randomized controlled study

OBJECTIVES

The purpose of this present study was to evaluate the efficiency of the growth factors delivered by concentrated growth factor (CGF) on the healing process of osteoporotic patients with medication-related osteonecrosis of the jaws (MRONJ).

METHODS

This randomized controlled study was composed of osteoporotic female patients who were treated with oral bisphosphonates (BPs) and diagnosed with MRONJ. For the CGF group, each patient was treated with a local application of CGF at the surgical site after removing the necrotic bone, while the surgical area was primarily closed as traditional surgical therapy for the control group. The patients underwent clinical examinations for 6 months postoperatively to check the presence of infection and dehiscence.

RESULTS

Complete healing was achieved in 19 patients of 28 patients (mean age: CGF group, 73.57 ± 5.1; control group, 73.64 ± 5.49) diagnosed with MRONJ. There was no significant difference in post-op healing data between groups during healing periods (p > 0.05). In the CGF group (n = 14) in three cases, bone exposure without infection was detected, and one of them showed a recurrent infection. In the control group (n = 14) in six cases, bone exposure without infection was detected, and three of them also showed recurrent infection.

CONCLUSION

Although our results were not statistically significant, our findings suggest that the local application of CGF appears to be an effective approach to the surgical treatment of MRONJ in osteoporosis patients by improving tissue regeneration.

CLINICAL RELEVANCE

A specific treatment protocol to manage MRONJ is still controversial. This study justifies that CGF can be used in combination with surgical treatment.

Platelet Rich Fibrin (PRF) Application in Oral Surgery

Platelet rich fibrin (PRF) is an autologous biological product which becomes popular day by day and available in a wide variety of fields in medicine. Platelet concentrates which are introduced at the early 90s have evolved over the years. The use such autologous materials have become trendy in recent years to encounter demanding expectations of patients, improve treatment success and maximize patient comfort. Despite its increasing use in dentistry and oral surgery, the most indications and effects are still being discussed. PRF is easily accepted by patients because of its low cost, easy to receive, low donor morbidity, low postoperative complication and infection rate. This biomaterial may be a solution for patients who have strong negative beliefs about the use of allografts and xenografts or who are afraid of complications during the grafting procedure. The objectives of these technologies are to use their synergistic effect to improve the hard and soft tissue regeneration. PRF in oral surgery are used for alveolar bone reconstruction, dental implant surgery, sinus augmentation, socket preservation, osteonecrosis, oroantral fistula closure, struggling with oral ulcers, preventing swelling and edema constitution. This chapter aims to review the clinical applications of platelets in oral surgery and the role of molecular components in tissue healing.

Pathogenesis and multidisciplinary management of medication-related osteonecrosis of the jaw

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.

The effect of melatonin on prevention of bisphosphonate-related osteonecrosis of the jaw: an animal study in rats

Objectives

Melatonin induces human stem cells, converts pre-osteoblasts to mature osteoblasts, and reduces the duration of this transition. However, melatonin itself prevents activation of osteoclasts. Here, we evaluate the role of melatonin in prevention of bisphosphonate-related osteonecrosis of the jaw.

Materials and Methods

In this experimental-interventional study, 30 rats were evaluated in 3 groups. The first and second groups received saline and zoledronic acid, respectively, for 4 weeks and the third group received 4 weeks of zoledronic acid and 3 weeks of melatonin simultaneously. First-right-maxillary-molar extraction was performed for all animals, which were sacrificed after 4 weeks of recovery. The extraction sockets were examined histologically for the presence of osteonecrosis, number of osteoclasts and fibroblasts, severity of inflammation, and vascularization. Data were analyzed by chi-square, one-way ANOVA, Tukey, Kruskal–Wallis and Fisher’s exact statistical tests (α=0.05).

Results

Osteonecrosis was observed in 20%, 90%, and 70% of the first, second and third groups, respectively (P=0.008). The lowest number of osteoclasts and fibroblasts was seen in the third group.

Conclusion

Melatonin may effectively prevent some undesirable side effects of bisphosphonates. However, further studies are required to confirm the results of this study.

Weak evidence for the management of medication-related osteonecrosis of the jaw: An overview of systematic reviews and meta-analyses

BACKGROUND

Although several therapies are proposed for medication-related osteonecrosis of the jaw (MRONJ), to date there is no consensus or treatment protocol for MRONJ. This overview aims to summarize the available evidence on the management and outcomes of MRONJ.

METHODS

An electronic search without language or date restrictions occurred in five databases and gray literature for articles published until March 2020. This overview was performed according to the PICO format. The eligibility criteria comprised systematic reviews (RS) with or without meta-analyses that analyzed treatments outcomes for MRONJ. The methodological quality of each SR was evaluated using AMSTAR 2.

RESULTS

Fifteen studies published between 2014 and 2020 were included in this overview. The summary of the evidence showed that conservative treatment and low level laser therapy can yield favorable results for early stages of MRONJ whereas surgical treatment seems to be better for advanced stages. However, qualitative assessment of the SRs highlighted a global low level of quality.

CONCLUSIONS

There is weak evidence to support treatment protocols for MRONJ. Because of the low quality of the SRs, highlighted by this overview, no insightful therapeutic recommendations can be issued for any intervention for MRONJ.

Platelet-Rich Plasma (PRP) in Dental Extraction of Patients at Risk of Bisphosphonate-Related Osteonecrosis of the Jaws: A Two-Year Longitudinal Study

Dental extraction has often been described as the main trigger event of osteonecrosis of the jaws (ONJ). This longitudinal hospital-based study aimed to evaluate the outcome at 2 years of a standardized medical-surgical protocol for dental extraction, combined with platelet rich-plasma (PRP) application, compared with conventional protocol not combined with PRP or any other autologous platelet concentrate in cancer (ONC) and osteometabolic (OST) patients, at risk of bisphosphonate (BP)-related ONJ. Twenty patients were consecutively recruited: six received BPs for cancer skeletal-related events (34.17 ± 19.97 months), while fourteen received BPs for metabolic bone disease (74.5 ± 34.73 months). These patients underwent a standardized protocol for dental extraction, combined with autologous PRP application in the post-extraction socket. A total of 63 dental extractions were performed (24 and 39 in ONC and OST groups, respectively). As controls, historical cases, derived from the literature and including 171 ONC and 734 OST patients, were considered. The outcome of the surgical treatment was successful in all patients treated with PRP: two years after extraction, no patient had clinical or radiological signs of ONJ. When this datum was compared with historical controls, no statistically significant differences were found (p > 0.1). The combination of a standardized medical-surgical protocol with PRP application may contribute to limit the occurrence of BP-related ONJ, in both ONC and OST patients. Additional prospective studies with a larger patient sample are necessary to confirm this datum.

Efficacy of growth factors for the treatment of peri-implant diseases: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to conduct a systematic review and meta-analysis on the efficacy of growth factors (GF) on clinical outcomes after treatment (surgical/non-surgical) of peri-implant diseases (peri-implant mucositis and peri-implantitis).

MATERIALS AND METHODS

A protocol was developed to answer the following focused question: Is there any difference for the use of GF for treatment of peri-implant diseases versus comparative GF treatment or without GF? Electronic database and manual searches were independently conducted to identify randomized controlled trials (RCTs). Publications were selected based on eligibility criteria and then assessed for risk-of-bias using the Cochrane Handbook. The primary outcome was probing depth (PD) and bleeding on probing (BOP) reduction along with changes in vertical defect depth (VDD). Changes in clinical attachment level, gingival recession, and plaque index, among others, were studied as secondary outcomes. Based on primary outcomes, random-effects meta-analysis was conducted.

RESULTS

A total of five RCTs were included. GF enhance the reduction of PD (standardized mean difference (SMD) = - 1.28; 95% confidence interval (CI) - 1.75, - 0.79; p = < 0.0001) and BOP (SMD = - 1.23; 95% CI - 1.70, - 0.76; p = < 0.0001) in the management of peri-implant mucositis. For the treatment of peri-implantitis, the use of GF yielded to significantly greater improvement in VDD (SMD = 0.68; 95% CI 0.22, 1.14; p = 0.004); however, there were no significant differences in terms of PD (SMD = 0.08; 95% CI - 1.08, 1.26; p = 0.887) and BOP (SMD = 0.211; 95% CI - 0.20, 0.63; p = 0.317). The overall risk of bias of the included studies was low to unclear.

CONCLUSION

The results of the present systematic review suggest that the addition of GF might enhance the outcomes in the treatment of peri-implant mucositis. However, there is a lack of evidence for supporting additional benefit of GF managing peri-implantitis.

CLINICAL RELEVANCE

Within the limitations of the current systematic review and based on the meta-analyses, (1) the addition of GF for the treatment peri-implant mucositis might be associated with better outcomes in terms of PD and BOP, and (2) an additional benefit of GF for the treatment peri-implantitis could not be determined on the basis of the selected evidence.

Endothelial progenitors increase vascularization and improve fibroblasts function that prevent medication-related osteonecrosis of the jaw

OBJECTIVES

In a previous rat model, MRONJ occurrence was 50%. Our aim was to investigate the potential of endothelial progenitor cells (EPCs) to improve fibroblasts function and prevent MRONJ.

METHODS

Human gingival fibroblasts were cultured with EPC-conditioned media (EPC-CM); endothelial growth media (EGM-2) or DMEM followed by incubation with 10 µM zoledronic (ZOL) and dexamethasone (DEX). Cell proliferation and migration were assessed by XTT and scratch wound healing assays. In vivo, ten Lewis rats were treated weekly with ZOL and DEX for 11 weeks. After a week, EPCs or EGM-2 were injected to the gingiva around the molars. At 3 weeks, bilateral molars were extracted. After 8 weeks, wound healing was assessed, and serum VEGF and blood vessels were quantified.

RESULTS

ZOL/DEX significantly reduced fibroblasts proliferation and wound healing. Treatment with EPC-CM before ZOL/DEX improved cell proliferation, and scratch healing (p = .007, p = .023). In vivo, local EPC injection before tooth extraction increased serum VEGF (p = .01) and soft tissue vascularization (p = .05). Normal healing was similar (80%) in EPCs and EGM-2 groups.

CONCLUSION

EPC rescued fibroblasts from the cytotoxic effect of ZOL/DEX and elevated serum VEGF and vessel density that might reduce MRONJ occurrence to 20% compared to 50% in a similar model.

Is the application of platelet concentrates effective in the prevention and treatment of medication-related osteonecrosis of the jaw? A systematic review

The aim of this systematic review was to answer the question: Is the application of autologous platelet concentrates (APCs) effective in the prevention and treatment of medication-related osteonecrosis of the jaw (MRONJ)? A literature search of PubMed, Scopus, and Web of Science databases (articles published until June 30, 2019) was conducted, in accordance with the PRISMA statement, using search terms related to "platelet concentrate" and "osteonecrosis". The Jadad scale was used to assess the quality of the articles. Fisher's exact test was used to evaluate eventual differences between groups. Of 594 articles, 43 were included in the review (8 for MRONJ prevention and 35 for MRONJ treatment). Out of a total of 1219 dental extractions recorded (786 with APCs), only 12 cases of MRONJ have been reported (1%), all in patients with a history of high-dose antiresorptive treatment, and regardless of the use of APCs (p = 0.7634). Regarding MRONJ treatment, there were no statistically significant differences in terms of improvement between APC application and surgical treatment alone (p = 0.0788). Results are not sufficient to establish the effectiveness of APCs in the prevention and treatment of MRONJ. Randomized controlled trials with large sample size are needed.

Use of Platelet Rich Fibrin (PRF)-Based Autologous Membranes for Tooth Extraction in Patients under Bisphosphonate Therapy: A Case Report

Tooth extraction in patients treated with bisphosphonates (BPs) for osteoporosis or cancer exposes the patient to the risk of osteonecrosis of the jaw. An autologous membrane using platelet-rich fibrin (PRF) is an innovative technique to promote wound healing, which allows obtaining a hermetic closure of the post-extractive surgical site without the need of mucoperiosteal flaps or periosteal releasing incisions. Here, we report the case of a 70-year-old woman, in therapy with alendronate for 12 years, requiring the upper right premolar extraction because of a crown fracture. After the tooth extraction performed under antiseptic and antibiotic coverage, the PRF autologous membrane was placed on the surgical wound to close completely the post-extraction site. Follow-up visits were carried out after one, two, four weeks and two months from the intervention. The complete re-epithelization of the wound was observed without signs of infection. The use of PRF for the closure of post-extraction sockets in patients taking BPs appears to be a promising alternative to the more invasive surgical procedures. Future clinical trials will be pivotal in elucidating the effectiveness of PRF to prevent BP-related osteonecrosis after tooth extraction.

Treatment of Bisphosphonate-Related Osteonecrosis of the Jaw With Plasma Rich in Growth Factors After Dental Implant Surgery: A Case Report

Oral bisphosphonates are commonly used to improve bone density in patients who suffer from a variety of pathologies. However, they have also been known to cause bisphosphonate-related osteonecrosis of the jaws (BRONJ). The aim of this clinical case presentation is to (1) determine whether the currently recommended length of time that oral bisphosphonates should be discontinued, before performing dental implant surgery, is sufficient to prevent BRONJ and (2) to describe an alternative treatment for BRONJ. A 65-year-old female patient developed BRONJ after receiving mandibular dental implants 5 months after discontinuing alendronic acid (Fosamax). The BRONJ was treated by surgical osteotomy and plasma rich in growth factors (PRGF), and the patient was followed up with biweekly examinations, which included 0.2% chlorhexidine mouthwashes and removal of any remaining necrotic bone. The dental implants were loaded 41 weeks after surgery and followed up with periapical radiographs and implant stability quotient measurements at 3, 6, 12, and 24 months postloading. Although the Association of Oral and Maxillofacial Surgeons protocols for suspension of presurgical oral bisphosphonates were followed, this patient still developed BRONJ after implant surgery. While a multitude of treatments have been described in the literature, there is not enough scientific evidence to support any one treatment. Based on this clinical case, it can be concluded that the potential adverse effects of oral bisphosphonates on the jaws could be greater than expected and that treatment with PRGF produces promising results, although more long-term studies are necessary to confirm these findings.

Three-dimensional bone evaluation after surgical treatment with plasma rich in growth factors of Medication Related Osteonecrosis of the Jaw (MRONJ): A report of 3 cases

Introduction

Medication Related Osteonecrosis of the Jaw (MRONJ) is an adverse effect of antiresorptive and antiangiogenic agents that consists of progressive bone destruction in the maxillofacial area. The purpose of this study is to analyze the effect on bone volume of a surgical protocol using plasma rich in growth factors (PRGF) for successfully treating MRONJ.

Methods

Three patients were treated combining surgical debridement with PRGF. Cone bean computed tomography scans were taken prior to surgery and 12 months after to measure bone volume changes. Biopsies were taken for histology analysis during surgery.

Results

All patients showed a complete soft tissue and bone healing with pain, discomfort, and neural symptoms resolution for a follow up period of 30 months. A total of 12 to 30% of bone volume gain was found at 12 months after surgery.

Conclusions

PRGF in combination with surgery may be effective in treating MRONJ. Future trials must be performed to confirm these results, including bone volume analysis.

Advance on Resveratrol Application in Bone Regeneration: Progress and Perspectives for Use in Oral and Maxillofacial Surgery

The natural polyphenol Resveratrol (RSV) claims numerous positive effects on health due to the well documented biological effects demonstrating its potential as a disease-preventing agent and as adjuvant for treatment of a wide variety of chronic diseases. Since several studies, both in vitro and in vivo, have highlighted the protective bone aptitude of RSV both as promoter of osteoblasts' proliferation and antagonist of osteoclasts' differentiation, they could be interesting in view of applications in the field of dentistry and maxillofacial surgery. This review has brought together experimental findings on the use of RSV in the regeneration of bone tissue comprising also its application associated with scaffolds and non-transfusional hemocomponents.

The use of Platelet-rich Fibrin in the management of medication-related osteonecrosis of the jaw: A case series

Medication related osteonecrosis of the jaw (MRONJ) is characterized by exposed necrotic bone in the maxillofacial region that persists for more than eight weeks in patients taking antiresorptive or antiangiogenic drugs for bone metastasis or osteoporosis. The management of such condition depends on several factors, among which the staging of MRONJ. Though, a specific gold standard treatment has not been established to date. The aim of this case series is to describe the outcome of surgical treatment of MRONJ with the adjunct of Platelet-rich Fibrin (PRF). Eleven patients under therapy with alendronate underwent surgical removal of necrotic bone and debridement, followed by placement of PRF membranes in the bone defect. The outcome of the surgical treatment was successful in all patients, in a follow-up range from 12 to 36 months. In the cases presented, the macroscopic evaluation showed excellent and fast soft tissue healing, with no recurrence of bone exposure and no signs of infections. PRF membranes were also effective for postsurgical pain control. The use of PRF may represent a valuable adjunct in the surgical management of MRONJ.

Extensive osteonecrosis of the maxilla caused by bisphosphonates: Report of a rare case

Bisphosphonates are drugs indicated for the treatment of bone metabolic diseases or malignant hypercalcemia. They are generally well-tolerated drugs, however, recent reports have described osteonecrosis of the jaw bones as a potentially serious complication related to the long-term use of these drugs. We report a case of severe osteonecrosis in a 52-years-old white woman that was taking bisphosphonates (zoledronic acid and alendronate) for the management of osteoporosis. Following a long exposure to these drugs and after being subjected to multiples exodontias, developed bisphosphonate-related osteonecrosis of the jaw compromising the whole maxilla and that extended toward the base of skull. Due to the extent of osteonecrosis, total maxillectomy and removal of all adjacent necrotic bone were planned guided by ultraviolet light. fluorescence. This case illustrates that if not treated correctly, bisphosphonate-related osteonecrosis of the jaw may cause significant morbidity, affect the quality of life and can eventually produce significant morbidity with the dissemination to noble structures and potentially causing life-threatening complications.

Key words:Osteonecrosis, bisphosphonate, bisphosphonate-associated osteonecrosis of the jaw, maxilla, osteoporosis.

Application of Autologous Platelet-Rich Plasma on Tooth Extraction Site Prevents Occurence of Medication-Related Osteonecrosis of the Jaws in Rats

This study evaluated the effects of local application of autologous platelet-rich plasma (PRP) on the tooth extraction site of rats presenting the main risk factors for medication-related osteonecrosis of the jaw (MRONJ). For seven weeks, senile rats were submitted to systemic treatment with vehicle (VEH and VEH-PRP) or 100 μg/Kg of zoledronate (ZOL and ZOL-PRP) every three days. After three weeks, the first lower molar was extracted. VEH-PRP and ZOL-PRP received PRP at the tooth extraction site. Euthanasia was performed at 28 days postoperatively. Clinical, histopathological, histometric and immunohistochemical analyses were carried out in histological sections from the tooth extraction site. ZOL showed lower percentage of newly formed bone tissue (NFBT), higher percentage of non-vital bone tissue (NVBT), as well as higher immunolabeling for TNFα and IL-1β. In addition, ZOL presented lower immunolabeling for PCNA, VEGF, BMP2/4, OCN and TRAP. VEH and ZOL-PRP showed improvement in the tooth extraction site wound healing and comparable percentage of NFBT, VEGF, BMP2/4 and OCN. Local application of autologous PRP proved a viable preventive therapy, which is safe and effective to restore tissue repair capacity of the tooth extraction site and prevent the occurrence of MRONJ following tooth extraction.

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

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

Conservative Surgical Treatment of Bisphosphonate-Related Osteonecrosis of the Jaw with Er,Cr:YSGG Laser and Platelet-Rich Plasma: A Longitudinal Study

Introduction

The management of bisphosphonate-related osteonecrosis of the jaw (BRONJ), with no evidence-based guidelines, remains controversial. We aimed to evaluate the efficiency of a conservative surgical treatment combining Er,Cr:YSGG laser and platelet-rich plasma (PRP) for the treatment of BRONJ in cancer patients.

Methods

We performed a longitudinal cohort study. Inclusion criteria were (1) age ≥ 18 years; (2) cancer diagnosis; (3) treatment with NBP because of the underlying cancer.

Results

We consecutively recruited ten patients diagnosed with BRONJ in stage I or II. These patients underwent a surgical laser-assisted therapy together with autologous PRP. At the latest follow-up at 12 months, clinical improvement was observed in eight patients. Registration Number is IRCT20180329039159N1.

Conclusion

We could successfully manage the BRONJ utilizing this combined protocol to heal the 30% of surgically treated sites and to improve the 50% of patients' lesions clinically. Our findings suggest that a surgical approach combined with Er,Cr:YSGG laser and PRP benefit cancer patients with general health issues.

Risk-reductive dental strategies for medication related osteonecrosis of the jaw among cancer patients: A systematic review with meta-analyses

The purpose of this systematic review with meta-analysis was to assess the effectiveness of dental interventions in preventing or reducing the incidence of medication-related osteonecrosis of the jaw (MRONJ) in cancer patients receiving antiresorptive therapy, compared to similar control groups receiving no intervention. Randomized controlled trials (RCT), case-controls and cohorts on cancer patients with primary outcome being the prevalence of MRONJ were included. Four electronic databases were searched (Cochrane Library, PubMed, EMBASE and Web of Science) up to February 12, 2018. A total of 409 abstracts were assessed and one case-control, one RCT and four cohort studies with 2332 cancer patients met our inclusion criteria. Risk of bias analysis followed Cochrane's handbook. Risk of bias was unclear for the case-control study and high risk for the RCT and all cohort studies. Five studies utilized preventive measures consisting of an initial examination and performing all necessary dental treatment before patients initiated antiresorptive therapy; one study used specialized post-extraction protocols utilizing plasma-rich in growth factors (PRGF) on cancer patients receiving antiresorptive therapy. Though dental preventive measures decreased MRONJ incidence by 77.3% in six studies with 2332 cancer patients (95% CI = 47.4-90.2%; p = .001) compared to control groups, quality of the evidence was low due to high or unclear risk of bias and the observational nature of five of the included studies. In conclusion, high-quality long-term prospective large sample size studies are needed to confirm these results due to high risk of bias and heterogeneous interventions. No funding.

Can platelet-rich fibrin improve healing after surgical treatment of medication-related osteonecrosis of the jaw? A pilot study

OBJECTIVE

The aim of this study was to evaluate the efficacy of platelet-rich fibrin (PRF) after bone surgery compared to surgery alone in the treatment of medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

A total of 47 patients with diagnosis of stage II or III of MRONJ were recruited at the Academic Hospital of Magna Graecia University of Catanzaro and allocated to 2 groups: In the first, patients were treated with PRF in addition to surgery (PRF group), in the other, only bone surgery was performed (non-PRF group). Fisher's exact and Student t tests were used to evaluate differences between the 2 surgical protocols in terms of mucosal integrity, absence of infection, and pain evaluation at scheduled follow-ups of 1 month (T1), 6 months (T2), and 1 year (T3).

RESULTS

Analysis of mucosal integrity, absence of infection, and pain evaluation showed a significant difference between the 2 groups in favor of PRF only at T1 (P < .05), whereas no differences were determined at T2 and T3 (P > .05).

CONCLUSIONS

Our results suggested that local application of PRF after bone surgery may improve the quality of life limited to the short-term follow-up and reduce pain and postoperative infections.

Beneficial Effects of Concentrated Growth Factors and Resveratrol on Human Osteoblasts In Vitro Treated with Bisphosphonates

Bisphosphonates are primary pharmacological agents against osteoclast-mediated bone loss and widely used in the clinical practice for prevention and treatment of a variety of skeletal conditions, such as low bone density and osteogenesis imperfecta, and pathologies, such as osteoporosis, malignancies metastatic to bone, Paget disease of bone, multiple myeloma, and hypercalcemia of malignancy. However, long-term bisphosphonate treatment is associated with pathologic conditions including osteonecrosis of the jaw, named BRONJ, which impaired bone regeneration process. Clinical management of BRONJ is controversy and one recent approach is the use of platelet concentrates, such as Concentrated Growth Factors, alone or together with biomaterials or antioxidants molecules, such as resveratrol. The aim of the present study was to investigate the in vitro effects of Concentrated Growth Factors and/or resveratrol on the proliferation and differentiation of human osteoblasts, treated or not with bisphosphonates. Human osteoblasts were stimulated for 3 days in complete medium and for 21 days in mineralization medium. At the end of the experimental period, the in vitro effect on osteoblast proliferation and differentiation was evaluated using different techniques such as MTT, ELISA for the quantification/detection of osteoprotegerin and bone morphogenetic protein-2, immunohistochemistry for sirtuin 1 and collagen type I, and the Alizarin Red S staining for the rate of mineralization. Results obtained showed that Concentrated Growth Factors and/or resveratrol significantly increased osteoblast proliferation and differentiation and that the cotreatment with Concentrated Growth Factors and resveratrol had a protective role on osteoblasts treated with bisphosphonates. In conclusion, these data suggest that this approach could be promised in the clinical management of BRONJ.