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Munakata K, Miyashita H, Yamada Y, Soma T, Iwasaki R, Nakagawa T, Asoda S. Factors affecting the quality of life of patients with medication-related osteonecrosis of the jaw during treatment: A quality-of-life survey and causal analysis. J Craniomaxillofac Surg 2024; 52:715-721. [PMID: 38582669 DOI: 10.1016/j.jcms.2024.03.021] [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: 01/23/2024] [Accepted: 03/12/2024] [Indexed: 04/08/2024] Open
Abstract
This prospective cohort study aimed to investigate the impact of medication-related osteonecrosis of the jaw (MRONJ) on health-related quality of life (HRQOL) and oral health-related QOL (OHRQOL) and the association between the downstaging of MRONJ and OHRQOL. The HRQOL and OHRQOL of 44 patients with MRONJ were assessed using the SF-36v2 and the General Oral Health Assessment Index (GOHAI), respectively. Treatment was performed in accordance with the AAOMS position paper (2014). The SF-36v2 and GOHAI scores at the beginning of the survey were used to evaluate the impact of MRONJ on QOL. Potential confounders affecting the association between downstaging and QOL improvement were selected using directed acyclic graphs. Multiple regression analysis was performed to evaluate causal inferences. HRQOL scale scores declined below the national average. The three-component summary score (3CS), comprising the physical component summary (PCS), mental component summary (MCS), and role/social component summary (RCS), revealed that performance status and primary disease significantly affected the PCS and RCS (P = 0.005 and P < 0.001, respectively) and PCS and MCS (P = 0.024 and P = 0.003, respectively). The MRONJ stage did not influence the 3CS; however, OHRQOL declined in a stage-dependent manner (P = 0.005). Downstaging of MRONJ was independently associated with the improvement rate of the total GOHAI scores after adjusting for variables (P = 0.045). The HRQOL of patients with MRONJ declined; however, this may depend on the underlying disease status rather than the MRONJ stage. Improvement of the disease status can potentially predict an improvement in OHRQOL, regardless of the treatment modality.
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Affiliation(s)
- Kanako Munakata
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hidetaka Miyashita
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Yuka Yamada
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Tomoya Soma
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Ryotaro Iwasaki
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Taneaki Nakagawa
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Seiji Asoda
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Rodriguez AB, Alhachache S, Velasquez D, Chan HL. A systematic review of oral wound healing indices. PLoS One 2024; 19:e0290050. [PMID: 38330054 PMCID: PMC10852230 DOI: 10.1371/journal.pone.0290050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/31/2023] [Indexed: 02/10/2024] Open
Abstract
Wound healing monitoring for abnormality identification and intervention is crucial to securing a successful surgical outcome. Indices have been used to summarize the degree of healing. Given the increasing frequency of regenerative procedures which preserve dentition and implant stability, and the higher esthetic demands, an appraisal of the available indices is needed to identify the current knowledge gap. This study aimed to systematically review published oral wound healing indices and scores. MATERIALS AND METHODS A complete literature electronic search in 5 databases was conducted by two reviewers. A combination of keywords related to oral wound healing was used. RESULTS A total of 11 articles were included in the evaluation of various procedures (conventional periodontal procedures, guided tissue regeneration, soft tissue reconstruction procedures, and tooth extractions), at different time points (1 day to 12 weeks), with a focus on diverse clinical signs and symptoms. Frequently evaluated parameters included wound dehiscence/epithelialization (91%), tissue color (redness) (73%), suppuration (55%), swelling/edema (55%), and hemostasis (55%). Other less commonly used parameters include esthetics-related and patient-centered outcomes. CONCLUSION The available indices evaluate a diverse group of subjective clinical signs and symptoms to estimate the underlying biological healing events and assess the degree of clinical success. The majority of the included indices are not validated. Quantitative and objective subclinical parameters including blood perfusion, biomaterial stability, and completeness of epithelialization, are needed for customized wound healing care and better outcome prediction.
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Affiliation(s)
- Amanda Beatriz Rodriguez
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Sara Alhachache
- Department of Periodontics, University of Louisville School of Dentistry, Louisville, Kentucky, United States of America
| | - Diego Velasquez
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, United States of America
- Private Practice, Fenton, Michigan, United States of America
| | - Hsun-Liang Chan
- Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, United States of America
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Tempesta A, Capodiferro S, Di Nanna S, D'Agostino S, Dolci M, Scarano A, Gambarini G, Maiorano E, Favia G, Limongelli L. Medication-related osteonecrosis of the jaw triggered by endodontic failure in oncologic patients. Oral Dis 2023; 29:2799-2805. [PMID: 36403223 DOI: 10.1111/odi.14449] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/25/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe the association between endodontic treatment failure and medication-related osteonecrosis of the jaw (MRONJ) in a cohort of oncologic patients in therapy with antiresorptive and antiangiogenic drugs. MATERIALS AND METHODS Patients were selected as affected by MRONJ in absence of the common local risk factors (oral surgical procedures or ill-fitting dentures) but showing failure of previous endodontic treatment performed at least 6 months before the starting of antiresorptive/antiangiogenic therapies. Jaw lesions were all surgically treated and patients underwent a strict clinical and radiological follow-up. RESULTS Among 18 patients, who developed 18 MRONJ, the only detectable local risk factor was the presence of teeth with failed endodontic treatment (more precisely, root canal underfilling in eight cases, root canal overfilling in two cases, root perforation in three cases, root fracture in five cases). All patients completely healed after surgical procedure and no recurrence was observed. CONCLUSIONS Endodontic treatment failure should be considered a local risk factor for MRONJ development in oncologic patients. For such reason, it is mandatory to carefully evaluate them prior than the beginning of antiresorptive and antiangiogenic drugs administration.
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Affiliation(s)
- Angela Tempesta
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, Aldo Moro University, Bari, Italy
| | - Saverio Capodiferro
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, Aldo Moro University, Bari, Italy
| | - Simona Di Nanna
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, Aldo Moro University, Bari, Italy
| | - Silvia D'Agostino
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Marco Dolci
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Antonio Scarano
- Department of Innovative Technologies in Medicine and Dentistry, G. D'Annunzio University, Chieti, Italy
| | - Gianluca Gambarini
- Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Rome, Italy
| | - Eugenio Maiorano
- Department of Emergency and Organ Transplantation, Operating Unit of Pathological Anatomy, Aldo Moro University, Bari, Italy
| | - Gianfranco Favia
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, Aldo Moro University, Bari, Italy
| | - Luisa Limongelli
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, Aldo Moro University, Bari, Italy
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Liu FC, Luk KC, Chen YC. Risk comparison of osteonecrosis of the jaw in osteoporotic patients treated with bisphosphonates vs. denosumab: a multi-institutional retrospective cohort study in Taiwan. Osteoporos Int 2023; 34:1729-1737. [PMID: 37326685 PMCID: PMC10511380 DOI: 10.1007/s00198-023-06818-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
In this multi-institutional retrospective cohort study, we compared the long-term risk of osteonecrosis of the jaw following the use of denosumab vs. bisphosphonates in osteoporotic patients. After 2-year use, the likelihood of osteonecrosis of the jaw is lower with denosumab compared to bisphosphonates, and the difference increases with time. PURPOSE To compare the long-term risk of osteonecrosis of the jaw (ONJ) between osteoporotic patients treated with bisphosphonates (BPs) and denosumab. METHODS This multi-institutional retrospective cohort study included patients aged > 40 years with osteoporosis between January 2010 and December 2018. Patients who met the eligibility criteria were divided into BPs and denosumab groups by propensity score matching (PSM). The risk of ONJ of denosumab vs. BPs was estimated using a Cox proportional hazards model and was described by the cumulative incidence rate using the Kaplan-Meier method. RESULTS A total of 84,102 patients with osteoporosis were enrolled, among whom, 8962 were eligible for inclusion based on their first-line drug use (denosumab, n = 3,823; BPs, n = 5,139). Following PCM matching (1:1), the BPs and denosumab groups included 3665 patients each. The incidence density of ONJ in the denosumab and BPs matching groups was 1.47 vs. 2.49 events (per 1000 person-years), respectively. The hazard ratio of ONJ in the denosumab vs. BPs group was estimated as 0.581 (95% confidence interval: 0.33-1.04, p = 0.07). The cumulative incidence rates of ONJ in both groups were similar for the first and second years of drug use (p = 0.062), but significantly different from the third year onwards (p = 0.022). The severity of ONJ was not significantly different between the two groups. CONCLUSION In osteoporotic patients, after 2 years of use, the likelihood of ONJ being induced by denosumab is lower than that of BPs, and the difference increases with time.
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Affiliation(s)
- Fang-Chun Liu
- Department of Dentistry, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kwing-Chi Luk
- Department of Dentistry, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yung-Chih Chen
- Division of General Internal Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Yasui T, Nagamine H, Tanaka K, Kimura M, Karube T, Kawana H, Onizawa K. Treatment outcomes and time to healing of medication-related osteonecrosis of the jaw based on image findings. Dentomaxillofac Radiol 2023; 52:20220352. [PMID: 37192041 PMCID: PMC10304842 DOI: 10.1259/dmfr.20220352] [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: 10/26/2022] [Revised: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the prognostic treatment outcome of non-operative management of medication-related osteonecrosis of the jaw (MRONJ), particularly regarding the relationship between image findings and treatment outcomes. METHODS This single-center, retrospective observational study included patients with MRONJ who were conservatively treated between 2010 and 2020. All patients were evaluated in terms of MRONJ treatment outcomes, time to healing, and prognostic factors, including sex, age, underlying disease, antiresorptive drug type, discontinuation of antiresorptive treatment, chemotherapy, corticosteroid treatment, diabetes mellitus, location of MRONJ, clinical stage of MRONJ, and computed tomography image findings. RESULTS The complete healing rate among the patients was 68.5%. Cox proportional hazards regression analysis revealed that "Sequestrum formation" on the internal texture (hazard ratio = 3.66; 95% confidence interval, 1.30-10.29; P =.014) and chemotherapy (hazard ratio = 0.41; 95% confidence interval, 0.18-0.95; P =.037) were significantly associated with treatment outcome. The median time to healing in patients with "Sequestrum formation" on the internal texture (4.4 months) was significantly shorter than the median time to healing in those marked with "Sclerosis" or "Normal" (35.5 months; P <.001) and "Lytic changes with sclerosis" (14.5 months; P =.015). CONCLUSIONS The image findings on the internal texture of the lesions at the initial examination and chemotherapy were associated with the treatment outcomes of nonoperative management of MRONJ. The image findings of "Sequestrum formation" were associated with lesions taking a short time to heal and better outcomes, whereas "Sclerosis" and "Normal" were associated with lesions with longer healing times.
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Affiliation(s)
| | - Hiroki Nagamine
- Department of Dentistry and Oral Surgery, Federation of National Public Service Personnel Mutual Aid Associations Tachikawa Hospital, Tokyo, Japan
| | - Kenta Tanaka
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Moemi Kimura
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
| | - Takeshi Karube
- Department of Dentistry and Oral Surgery, School of Medicine, Keio University, Tokyo, Japan
| | | | - Katsuhiro Onizawa
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
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Badabaan G, Creanga AG, Singer SR, Strickland M, Subramanian G. Quantitative indices for cone-beam CT assessment of Medication-Related Osteonecrosis of the Jaw - a scoping review. Saudi Dent J 2023; 35:133-140. [PMID: 36942207 PMCID: PMC10024109 DOI: 10.1016/j.sdentj.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives It is not unusual for Medication-related osteonecrosis of the jaw (MRONJ) lesions that have similar clinical presentation and staging to have dissimilar radiographic extent of disease. The aim of this review was to explore the published scientific literature for quantitative indices that describe the cone-beam computerized tomography (CBCT) radiographic features of MRONJ lesions and assess their clinical utility. Method and Materials A scoping review of the literature was performed to identify quantitative indices developed to describe the CBCT radiographic features of MRONJ lesions. Five electronic databases were included in the review: PubMed, Scopus, Web of Science, Trip medical database, and Cochrane Library. Articles published from the year 2003 onward were included in the review. Results 367 articles were initially included in the review. 39 abstracts were screened for full-text assessment. The scoping review yielded 12 full length articles with169 cases reported. The Composite Radiographic Index score (CRI score) was identified as the most meaningful index in published literature that attempted to quantify qualitative radiographic changes (Walton, Grogan et al. 2019). However, lesions with similar CRI scores that corresponded to intermediate severity (3-5) may be very dissimilar radiographically in both nature and extent of radiographic changes, undercutting its clinical value. Conclusion The CRI index score was the only relevant index for cross-sectional (one-time) assessment of established MRONJ lesions (non-stage 0). This scoping review yielded several critical questions regarding the clinical significance and prognostic implications of various radiographic changes in MRONJ, thereby identifying focus areas for future research.
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Affiliation(s)
- Ghaidaa Badabaan
- Master of Dental Science, Rutgers School of Dental Medicine, Faculty of Dentistry, Umm Al-Qura University, Saudi Arabia
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
- Corresponding author.
| | - Adriana G. Creanga
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
| | - Steven R. Singer
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
| | - Maxine Strickland
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
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Gaudet C, Odet S, Meyer C, Chatelain B, Weber E, Parmentier AL, Derruau S, Laurence S, Mauprivez C, Brenet E, Kerdjoudj H, Fenelon M, Fricain JC, Zwetyenga N, Hoarau D, Curien R, Gerard E, Louvrier A, Gindraux F. Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations. Cells 2022; 11:4097. [PMID: 36552861 PMCID: PMC9777472 DOI: 10.3390/cells11244097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.
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Affiliation(s)
- Camille Gaudet
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
| | - Stephane Odet
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
| | - Christophe Meyer
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
- Laboratoire de Nanomédecine, Imagerie, Thérapeutique EA 4662, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Brice Chatelain
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
| | - Elise Weber
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
| | - Anne-Laure Parmentier
- Unité de Méthodologie, INSERM Centre d’Investigation Clinique 1431, CHU Besançon, F-25000 Besançon, France;
| | - Stéphane Derruau
- Pôle Médecine Bucco-Dentaire, Hôpital Maison Blanche, CHU Reims, F-51092 Reims, France; (S.D.); (S.L.); (C.M.)
- Laboratoire BioSpecT EA-7506, UFR de Pharmacie, Université de Reims Champagne-Ardenne, F-51100 Reims, France
| | - Sébastien Laurence
- Pôle Médecine Bucco-Dentaire, Hôpital Maison Blanche, CHU Reims, F-51092 Reims, France; (S.D.); (S.L.); (C.M.)
- Biomatériaux et Inflammation en Site Osseux, Pôle Santé, URCA, HERVI EA3801 UFR de Médecine, Université de Reims Champagne Ardenne, F-51100 Reims, France
| | - Cédric Mauprivez
- Pôle Médecine Bucco-Dentaire, Hôpital Maison Blanche, CHU Reims, F-51092 Reims, France; (S.D.); (S.L.); (C.M.)
- Biomatériaux et Inflammation en Site Osseux, Pôle Santé, URCA, BIOS EA 4691, Université de Reims Champagne Ardenne, F-51100 Reims, France;
- UFR d’Odontologie, Université de Reims Champagne Ardenne, F-51100 Reims, France
| | - Esteban Brenet
- Service d’ORL et Chirurgie Cervico-Faciale, CHU Reims, F-51092 Reims, France;
| | - Halima Kerdjoudj
- Biomatériaux et Inflammation en Site Osseux, Pôle Santé, URCA, BIOS EA 4691, Université de Reims Champagne Ardenne, F-51100 Reims, France;
- UFR d’Odontologie, Université de Reims Champagne Ardenne, F-51100 Reims, France
| | - Mathilde Fenelon
- CHU Bordeaux, Dentistry and Oral Health Department, F-33404 Bordeaux, France; (M.F.); (J.-C.F.)
- INSERM U1026, University of Bordeaux, Tissue Bioengineering (BioTis), F-33076 Bordeaux, France
| | - Jean-Christophe Fricain
- CHU Bordeaux, Dentistry and Oral Health Department, F-33404 Bordeaux, France; (M.F.); (J.-C.F.)
- INSERM U1026, University of Bordeaux, Tissue Bioengineering (BioTis), F-33076 Bordeaux, France
| | - Narcisse Zwetyenga
- Chirurgie Maxillo-Faciale-Stomatologie-Chirurgie Plastique Réparatrice et Esthétique-Chirurgie de La main, CHU Dijon, F-21079 Dijon, France; (N.Z.); (D.H.)
| | - David Hoarau
- Chirurgie Maxillo-Faciale-Stomatologie-Chirurgie Plastique Réparatrice et Esthétique-Chirurgie de La main, CHU Dijon, F-21079 Dijon, France; (N.Z.); (D.H.)
| | - Rémi Curien
- Service d’Odontologie, CHR Metz-Thionville, F-57530 Thionville, France; (R.C.); (E.G.)
| | - Eric Gerard
- Service d’Odontologie, CHR Metz-Thionville, F-57530 Thionville, France; (R.C.); (E.G.)
| | - Aurélien Louvrier
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
- INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | - Florelle Gindraux
- Service de Chirurgie Maxillo-Faciale, Stomatologie et Odontologie Hospitalière, CHU Besançon, F-25000 Besançon, France; (C.G.); (S.O.); (C.M.); (B.C.); (E.W.); (A.L.)
- Laboratoire de Nanomédecine, Imagerie, Thérapeutique EA 4662, Université Bourgogne Franche-Comté, F-25000 Besançon, France
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Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg 2022; 80:920-943. [PMID: 35300956 DOI: 10.1016/j.joms.2022.02.008] [Citation(s) in RCA: 312] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/13/2022]
Abstract
Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaws (MRONJ) - formerly referred to as bisphosphonate-related osteonecrosis of the jaws (BRONJ)-were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007, 2009 and 2014. The position papers were developed by a committee appointed by the AAOMS Board of Trustees and comprising clinicians with extensive experience in caring for these patients, as well as clinical and basic science researchers. The knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating modifications and refinements to the previous position papers. Three members of the AAOMS Committee on Oral, Head, and Neck Oncologic and Reconstructive Surgery (COHNORS) and three authors of the 2014 position paper were appointed to serve as a working group to analyze the current literature and revise the guidance as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis and management strategies and highlights the current research status. AAOMS maintains that it is vitally important for this information to be disseminated to other relevant healthcare professionals and organizations.
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Affiliation(s)
- Salvatore L Ruggiero
- Clinical Professor, Division of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Hofstra North Shore-LIJ School of Medicine, New York Center for Orthognathic and Maxillofacial Surgery, Lake Success, NY.
| | - Thomas B Dodson
- Professor and Chair, University of Washington School of Dentistry, Department of Oral and Maxillofacial Surgery, Seattle, Wash
| | - Tara Aghaloo
- Professor, Oral and Maxillofacial Surgery, UCLA School of Dentistry, Los Angeles, Calif
| | - Eric R Carlson
- Professor and Kelly L. Krahwinkel Endowed Chairman, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Brent B Ward
- Chalmers J Lyons Professor of Oral and Maxillofacial Surgery, Associate Professor of Dentistry, Chair of the Department of Oral and Maxillofacial Surgery/Hospital Dentistry in the School of Dentistry and Associate Professor of Surgery for the Medical School, University of Michigan Hospital, Ann Arbor, Mich
| | - Deepak Kademani
- Chief of Staff North Memorial Health, Fellowship Director, Oral/Head and Neck Oncologic and Reconstructive Surgery Attending Surgeon, North Memorial Health and the University of Minnesota. Private practice, Minnesota Oral and Facial Surgery and Minnesota Head and Neck Surgery, Minneapolis, Minn
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Ciobanu GA, Gheorghiţă MI, Petrescu OM, Popescu SM, Staicu IE. Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:117-122. [PMID: 34211758 PMCID: PMC8200619 DOI: 10.12865/chsj.47.01.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/27/2021] [Indexed: 11/18/2022]
Abstract
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
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Affiliation(s)
| | - Mircea Ionuţ Gheorghiţă
- Department of Oral and Maxillo-Facial Surgery, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Octavian Mihnea Petrescu
- Department of Oral and Maxillo-Facial Surgery, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Sanda Mihaela Popescu
- Department of Oral Rehabilitation and Medical and Surgical Emergencies, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania
| | - Ionela Elisabeta Staicu
- Department of Orthodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania
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Cunha VV, Silva PGDB, Lemos JVM, Martins JOL, Freitas MO, Avelar RL. Evaluation of a collagen matrix in a mandible defect in rats submitted to the use of bisphosphonates. Acta Cir Bras 2020; 35:e202001005. [PMID: 33263607 PMCID: PMC7709902 DOI: 10.1590/s0102-865020200100000005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/19/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To assess the effect of a collagen matrix (Mucograft®) on the inflammatory process in a semi-critical experimental defect model in rats treated with bisphosphonates. METHODS Eighteen Wistar rats were randomly divided into three groups: saline (CG), alendronate (ALD) 5mg/kg (AG) or zoledronic acid (ZA) 0.2mg/kg (ZG). ALD was administered orally for 10 weeks and ZA was administered intravascularly on days 0, 7 and 14 and 49. On day 42, a 2mm defect was created and filled with Mucograft® collagen matrix. The contralateral side was filled with a clot (control side). The animals were euthanized 70 days after the beginning of the experiment and the hemimandibles were radiographically and histologically (counting of empty osteocyte lacunae (%), apoptotic (%) and total osteoclasts, neutrophil and mononuclear inflammatory cells) analyzed. The variables were submitted to ANOVA/Bonferroni and t test (parametric data) (p <0.05, GraphPad Prism 5.0). RESULTS Significant bone repair occurred in the groups treated with Mucograft®. High number of total inflammatory cells and neutrophils cells were showed in AG (p=0.026 and p=0.035) and AZ groups (p=0.005, p=0.034) on the control sides associated with delayed bone repair and the presence of devitalized bone tissue in AG and ZG on the Mucograft® side. CONCLUSION Mucograft® collagen matrix attenuated the inflammatory process in a mandible defect in rats submitted to the use of bisphosphonates (AG and ZG).
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Affiliation(s)
- Vanessa Vasconcelos Cunha
- Fellow Master degree, Academic Master in Dental Sciences, School of Dentistry, Centro Universitário Christus (UNICHRISTUS), Fortaleza-CE, Brazil. Substantive scientific and intellectual contributions to the study
| | - Paulo Goberlânio de Barros Silva
- Professor, Division of Oral and Maxillofacial Surgery, School of Dentistry, UNICHRISTUS, Fortaleza-CE, Brazil. Critical revision, final approval
| | - José Vitor Mota Lemos
- Dentist, School of Dentistry, UNICHRISTUS, Fortaleza-CE, Brazil. Statistics analysis, manuscript preparation
| | | | - Milena Oliveira Freitas
- Dentist, School of Dentistry, UNICHRISTUS, Fortaleza-CE, Brazil. Acquisition, analysis and interpretation of data; technical procedures
| | - Rafael Linard Avelar
- Professor, Division of Oral and Maxillofacial Surgery, School of Dentistry, UNICHRISTUS, Fortaleza-CE, Brazil. Critical revision, final approval
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Hallmer F, Bjarnadottir O, Götrick B, Malmström P, Andersson G. Incidence of and risk factors for medication-related osteonecrosis of the jaw in women with breast cancer with bone metastasis: a population-based study. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:252-257. [PMID: 32536575 DOI: 10.1016/j.oooo.2020.04.808] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/13/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to prospectively determine the incidence of medication-related osteonecrosis of the jaw (MRONJ) and define risk factors in patients with metastatic breast cancer treated with zoledronic acid and/or denosumab. STUDY DESIGN In a prospective cohort study performed in Region Skåne, Sweden, from January 1, 2012, until December 31, 2015, all patients with breast cancer who had radiographic evidence of bone metastases and were treated with zoledronic acid or denosumab were included and followed up until May 31, 2018. RESULTS Of the 242 patients, MRONJ developed in 16 (6.6%) during the 77 months of study. The incidence of MRONJ in patients treated with zoledronic acid was 4.1%, and in patients treated with denosumab, it was 13.6%. The risk of MRONJ was higher in patients on denosumab than in those treated with zoledronic acid (P = .011). Corticosteroid use was associated with a decreased risk of MRONJ (P = .008), and diabetes was associated with an increased risk of MRONJ (P = .02). CONCLUSIONS The incidence of MRONJ is 13.6% (>3 times higher) in denosumab-treated patients with breast cancer compared with that in patients treated with zoledronic acid (4.1%). Corticosteroid use decreased the risk of MRONJ.
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Affiliation(s)
- Fredrik Hallmer
- Consultant, Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden and Department of Oral and Maxillofacial Surgery, Skåne University Hospital, Lund, Sweden.
| | - Olof Bjarnadottir
- Consultant, Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Bengt Götrick
- Associate Professor and Head, Department of Oral Diagnostics, Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Per Malmström
- Professor, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Gunilla Andersson
- Associate Professor, Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden
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Hauer L, Jambura J, Hrusak D, Chalupova M, Posta P, Rusnak S, Vyskocil V. Surgical therapy for medication-related osteonecrosis of the jaw in osteoporotic patients treated with antiresorptive agents. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:100-107. [DOI: 10.5507/bp.2018.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/18/2018] [Indexed: 11/23/2022] Open
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Tartaroti NC, Marques MM, Naclério-Homem MDG, Migliorati CA, Zindel Deboni MC. Antimicrobial photodynamic and photobiomodulation adjuvant therapies for prevention and treatment of medication-related osteonecrosis of the jaws: Case series and long-term follow-up. Photodiagnosis Photodyn Ther 2020; 29:101651. [PMID: 31923636 DOI: 10.1016/j.pdpdt.2020.101651] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/06/2019] [Accepted: 01/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Medication-Related Osteonecrosis of the Jaws (MRONJ) incidence are increasing among elderly. Treatment can be challenging. Prevent or treatment protocols that control evolution of the lesion are warranted. OBJECTIVE To observe long-term outcomes of two protocols based on photonics [antimicrobial photodynamic therapy (aPDT) and photobiomodulation (PBM)] for prevention and treatment of MRONJ lesions. METHODS In a prospective study, patients who needed oral surgery and had been exposed to antiresorptive drugs were long-term followed-up. For MRONJ prevention, immediately after tooth extraction aPDT was applied. For aPDT a 0.01 % methylene blue solution was applied inside socket for 5 min followed by irradiation with a diode laser [660 nm, 0.028cm2, 0.1 W, 3.57 W/cm2, 90 s and 9 J per point, 321 J/cm2, at least at in 3 points (laser probe was placed at central, and two equidistant points) and total energy of 27J]. Irradiation was repeated weekly until total tissue repair. MRONJ treatment included preoperative aPDT sessions until signs and symptoms of infection had reduced. Then, after necrotic bone removal, aPDT was applied inside surgical wounds and re-applied weekly until healing. Antibiotics were administered pre or postoperatively for no longer than 7 days. PBM therapy was applied with 808 nm diode laser, 0.028cm2, 0.1 W, 3.57 W/cm2, 30 s, 107 J/cm², 3 J and total energy of 12 J until evidence of remission. RESULTS Eighteen patients underwent preventive protocol, and none presented signs of MRONJ after a follow-up of at least 6 months. Seventeen patients presented with MRONJ underwent aPDT protocol and sixteen of them showed total regression of lesions. PRACTICAL IMPLICATIONS aPDT and PBM therapy protocols appear to be effective as adjuvant approach not only for preventing MRONJ development due to tooth extraction but for treating MRONJ lesions at early stages with no adverse effects.
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Affiliation(s)
- Natália Caroline Tartaroti
- Department of Oral and Maxillofacial Surgery- School of Dentistry - University of Sao Paulo FOUSP, Av. Prof. Lineu Prestes 2227, Butantã, São Paulo, 5508-000, São Paulo Brazil.
| | - Márcia Martins Marques
- Post Graduation Program - School of Dentistry - Ibirapuera University - UNIb, Av. Interlagos, 1329 - 4º - Chácara Flora, São Paulo, SP, 04661-100, Brazil.
| | - Maria da Graça Naclério-Homem
- Department of Oral and Maxillofacial Surgery- School of Dentistry - University of Sao Paulo FOUSP, Av. Prof. Lineu Prestes 2227, Butantã, São Paulo, 5508-000, São Paulo Brazil.
| | - Cesar Augusto Migliorati
- Department of Oral and Maxillofacial Diagnostic - University of Florida College of Dentistry, 1395 Center Drive, Rm D3-9 PO Box 100412 Gainesville, FL 32610-0412 USA.
| | - Maria Cristina Zindel Deboni
- Department of Oral and Maxillofacial Surgery- School of Dentistry - University of Sao Paulo FOUSP, Av. Prof. Lineu Prestes 2227, Butantã, São Paulo, 5508-000, São Paulo Brazil.
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Özalp Ö, Toru HS, Altay MA, Sindel A. Evaluation of the Efficacy of EDTA Chelation on Alveolar Bone Healing After Ultrasonic and Conventional Surgery Under Bisphosphonate Medication: A Rat Model. J Oral Maxillofac Surg 2019; 77:1982-1989. [PMID: 31095928 DOI: 10.1016/j.joms.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE The aims of the present study were 1) to investigate the effects of local ethylenediaminetetraacetic acid (EDTA) chelation on alveolar bone healing after systemic administration of bisphosphonates; and 2) to compare the healing in alveolar defects created with ultrasonic and conventional surgery. MATERIALS AND METHODS A total of 40 male Wistar rats were divided into 4 equal groups of 10 rats each (zoledronate and piezosurgery, zoledronate and bur, placebo and piezosurgery, and placebo and bur). The first 2 groups received weekly intraperitoneal injections of zoledronic acid (0.06 mg/kg), and the second 2 groups received saline solution for 4 weeks. After the last injections, horizontal defects 4 × 2 × 1 mm in size were created on the mandibular alveolar bone using piezosurgery or conventional bur surgery. The zoledronate groups received 10 minutes of local application of EDTA on 1 side and saline solution on the other side. In the placebo groups, only 1 side was treated (one half of the group with the bur and one half of the group with piezosurgery). All the rats were euthanized at 4 postoperative weeks for comparative histomorphometric evaluation of bone healing in the created defects. RESULTS Bone formation was found to be the greatest in the placebo groups (P < .05). Although a greater amount of bone formation was observed with piezosurgery and EDTA among the bisphosphonate-treated groups, the difference between the zoledronate groups was not statistically significant (P > .05). Similarly, no statistically significant difference was found between the use of piezosurgery and conventional bur surgery within the placebo groups (P > .05). CONCLUSIONS The findings of the present study revealed improved bone healing with the use of piezosurgery and EDTA chelation, although the difference did not reach statistical significance. Further research should be performed to clearly identify the role of EDTA as a chelating agent and in prevention of medication-related osteonecrosis of the jaws development.
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Affiliation(s)
- Öznur Özalp
- Specialist, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Akdeniz University, Antalya, Turkey.
| | - Havva Serap Toru
- Associate Professor, Department of Pathology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Mehmet Ali Altay
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Akdeniz University, Antalya, Turkey
| | - Alper Sindel
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Akdeniz University, Antalya, Turkey
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Treatment outcomes and prognostic factors of medication-related osteonecrosis of the jaw: a case- and literature-based review. Clin Oral Investig 2018; 23:3203-3211. [PMID: 30406491 DOI: 10.1007/s00784-018-2743-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/31/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the treatment outcomes and prognostic factors of medication-related osteonecrosis of the jaw (MRONJ) in Japanese patients. PATIENTS AND METHODS Among 409 cases, treatment outcomes and prognostic factors were investigated in 275 patients. In statistical analyses, the 1-year cumulative curative rate was calculated with the Kaplan-Meier method, and significance was examined with the Wilcoxon test. Cox's proportional hazards regression analysis was used for the multivariate analysis. RESULTS Resolution of the disease was achieved in 137 out of 275 MRONJ patients (49.8%). One-year cumulative curative rates were 39.8% in stage 1 patients, 26.3% in stage 2, and 19.0% in stage 3. The 1-year cumulative curative rates of treatment interventions were 17.2% for conservative treatment, 34.5% for sequestrectomy, and 40.7% for extended surgery including bone resection and segmental resection. As the prognostic factors of treatment outcomes, the type of medication, stage of MRONJ, and type of surgical intervention were identified as independent factors in a multivariate analysis. CONCLUSION These results suggest that surgical interventions may lead to a good prognosis in MRONJ patients. CLINICAL RELEVANCE This study indicated that surgical intervention for MRONJ might lead to improvement of prognosis and quality of life in MRONJ patients.
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Akashi M, Kusumoto J, Takeda D, Shigeta T, Hasegawa T, Komori T. A literature review of perioperative antibiotic administration in surgery for medication-related osteonecrosis of the jaw. Oral Maxillofac Surg 2018; 22:369-378. [PMID: 30327979 DOI: 10.1007/s10006-018-0732-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 10/09/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Few studies exist that focus on the details of perioperative antibiotic administration for surgery to treat medication-related osteonecrosis of the jaw (MRONJ). The regime and duration of perioperative antibiotics applied in published studies were reviewed to clarify appropriate perioperative antibiotic use in MRONJ surgery. METHODS A literature search was conducted using the MEDLINE database via PubMed. RESULTS The search resulted in 453 hits on PubMed. After reading the downloaded full-text articles, 17 articles met the inclusion and exclusion criteria. The most common perioperative antibiotic used for MRONJ surgery was a combination of penicillin-based antibiotics and β-lactamase inhibitor (52.9%), and the second most common regime was penicillin-based antibiotics with metronidazole (17.6%). The duration of administration was 2 weeks postoperatively in nine studies, whereas four studies applied long-term administration (2-6 weeks postoperatively). CONCLUSIONS Oral and maxillofacial surgeons mostly prefer penicillin-based antibiotics plus β-lactamase inhibitor or metronidazole for MRONJ surgery. The duration of administration of these medications may be based on empirical experience.
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Affiliation(s)
- Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Junya Kusumoto
- Department of Oral and Maxillofacial Surgery, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-cho, Kakogawa, 675-8611, Japan
| | - Daisuke Takeda
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takashi Shigeta
- Department of Oral and Maxillofacial Surgery, Hyogo Cancer Center, 13-70 Kitaouji-cho, Akashi, 673-0021, Japan
| | - Takumi Hasegawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takahide Komori
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Hallmer F, Andersson G, Götrick B, Warfvinge G, Anderud J, Bjørnland T. Prevalence, initiating factor, and treatment outcome of medication-related osteonecrosis of the jaw-a 4-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:477-485. [PMID: 30249535 DOI: 10.1016/j.oooo.2018.08.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 07/01/2018] [Accepted: 08/22/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medication-related osteonecrosis of the jaw (MRONJ) has a wide range of prevalence, and a standard therapy has not yet been established. The aim of this study was to analyze the prevalence and initiating factors of MRONJ and the outcomes of surgical therapy. STUDY DESIGN In a prospective cohort study, all patients diagnosed with MRONJ in the Region of Skåne, in Sweden, were included. Predictor variables (comorbidity, site, stage, gender) and initiating factors (tooth extraction, periodontitis) were recorded. Surgical treatment was sequestrectomy or block resection, and the outcome variable was healing after 2 months. To estimate the prevalence, data on the use of bisphosphonate and denosumab were used. RESULTS Fifty-five patients with MRONJ were identified. The prevalence of MRONJ was 0.043% among patients treated with oral bisphosphonates, 1.03% among those on intravenous bisphosphonates and 3.64% in those on high-dose denosumab. Periodontal disease preceded development of MRONJ in 41 patients. Fifty patients were treated surgically and followed up for at least 2 months. Remission or healing occurred in 80% of patients treated with sequestrectomy and in 92.5% of patients treated with block resection. CONCLUSIONS The prevalence of MRONJ in Sweden is low. Periodontitis is the most common initiating factor. The outcome of treatment of MRONJ is healing in most patients treated surgically.
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Affiliation(s)
- Fredrik Hallmer
- Consultant, Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden; Skåne University Hospital, Kristianstad, Helsingborg, Malmö, Lund, Sweden.
| | - Gunilla Andersson
- Associate Professor, Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Bengt Götrick
- Associate Professor and Head, Department of Oral Diagnostics, Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Gunnar Warfvinge
- Professor and Head, Department of Oral Pathology, Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Jonas Anderud
- Consultant, Department of Oral and Maxillofacial Surgery, Maxillofacial Unit, Hallands Hospital, Halmstad, Sweden
| | - Tore Bjørnland
- Professor and Chairman, Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo, Oslo, Norway
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Karna H, Gonzalez J, Radia HS, Sedghizadeh PP, Enciso R. Risk-reductive dental strategies for medication related osteonecrosis of the jaw among cancer patients: A systematic review with meta-analyses. Oral Oncol 2018; 85:15-23. [PMID: 30220314 DOI: 10.1016/j.oraloncology.2018.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/01/2018] [Accepted: 08/05/2018] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Harry Karna
- Master of Science in Orofacial Pain and Oral Medicine Program, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, CA, USA
| | - Jaime Gonzalez
- Master of Science in Orofacial Pain and Oral Medicine Program, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, CA, USA
| | - Harveen S Radia
- Master of Science in Orofacial Pain and Oral Medicine Program, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, CA, USA
| | - Parish P Sedghizadeh
- Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Reyes Enciso
- Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, CA, USA.
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Ramaglia L, Guida A, Iorio-Siciliano V, Cuozzo A, Blasi A, Sculean A. Stage-specific therapeutic strategies of medication-related osteonecrosis of the jaws: a systematic review and meta-analysis of the drug suspension protocol. Clin Oral Investig 2018; 22:597-615. [PMID: 29332231 DOI: 10.1007/s00784-017-2325-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/20/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The most debated topic about medication-related osteonecrosis of the jaws (MRONJ) is its therapy, as there are no definitive guidelines. The aims of this systematic review were (a) to outline the best therapeutic approach according to the stage at diagnosis and (b) to perform a meta-analysis to assess whether the drug-holiday protocol may be or not an effective method in the management of MRONJ patients. MATERIALS AND METHODS The systematic review was performed following the PRISMA principles. Results were screened according to inclusion and exclusion criteria regarding staging before/after treatment, follow-up, and information provided by the authors. For statistical analysis, linear variables are reported as means and standard deviations, medians, and inter-quartile range (IQR); normality of data, according to the distribution of complete healing (primary outcome variable), was assessed with the Kolmogorov-Smirnov test. A p value < 0.05 was considered statistically significant for all tests. RESULTS Thirteen studies were selected out of 1480. None of them was case-controlled or randomized. Conservative approach showed good results at early stages, but heterogeneous result at advanced stages (100% stage 0, stage I range 81-97%, stage II range 63.6-100%, stage III 73%). Surgical approach showed heterogeneous results at all stages (stage I range 0-100%, stage II range 52-100%, stage III range 50-100%). Statistical analysis showed a significantly higher prevalence of completely healed sites in patients who followed the drug-holiday protocol. CONCLUSIONS The results suggest that the current stage-specific approach for MRONJ therapy is based on a sound clinical rationale. Conservative treatment appears to yield better outcomes at early stages, while further investigations are needed to elucidate the best protocols for the management of advanced stages. The drug-holiday protocol statistically promotes complete healing after oral surgery procedures but the application should be dictated by the condition of each patient. CLINICAL RELEVANCE At present, early MRONJ stages should be primarily treated by means of a conservative approach while more advanced stages must be carefully evaluated. Individual decisions should be made for every single case even with respect to the drug-holiday protocol.
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Affiliation(s)
- Luca Ramaglia
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Agostino Guida
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Vincenzo Iorio-Siciliano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Alessandro Cuozzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Andrea Blasi
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Anton Sculean
- Department of Periodontology, School of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010, Bern, Switzerland.
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Coropciuc RG, Grisar K, Aerden T, Schol M, Schoenaers J, Politis C. Medication-related osteonecrosis of the jaw in oncological patients with skeletal metastases: conservative treatment is effective up to stage 2. Br J Oral Maxillofac Surg 2017; 55:787-792. [PMID: 28760314 DOI: 10.1016/j.bjoms.2017.06.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/22/2017] [Indexed: 11/18/2022]
Abstract
There is currently no widespread strategy for treating medication-related osteonecrosis of the jaw (MRONJ), so our aim was to evaluate retrospectively the outcome of a minimally invasive treatment protocol for patients with both MRONJ and cancer. We designed a retrospective cohort study of patients with cancer who had been diagnosed with MRONJ after treatment with denosumab or bisphosphonates given intravenously. Primary outcome measures were improvement in the clinical stage of MRONJ and the time course to its resolution. Secondary outcome measures included the incidence of risk factors and patterns of treatment. Seventy-nine patients with 109 lesions were enrolled, and their characteristics, presentation of the lesions, complications, and relations to previous oral interventions were recorded. Treatment depended on the stage of disease, and included conservative medical, and minimally-invasive surgical, procedures. There was complete healing and resolution of disease in 38/57 stage 1 lesions, 30/47 stage 2 lesions, and 3/5 stage 3 lesions. The symptoms improved in 16/47 stage 2 lesions, and 2/5 stage 3 lesions. Fifteen of the stage 1 lesions, and one of the stage 2 lesions, failed to respond. Despite the possibility of an aggressive approach to the treatment of MRONJ, conservative treatment remains the first line of defence as regression is obvious, with evidence of no evolution to a higher stage. In our experience surgical intervention is recommended in persistent stage 3 MRONJ that has failed to respond to conservative treatment.
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Affiliation(s)
- R G Coropciuc
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - K Grisar
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - T Aerden
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M Schol
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - J Schoenaers
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - C Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
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Suzuki N, Oguchi H, Yamauchi Y, Karube Y, Suzuki Y, Hosoya N. A case of tooth fracture occurred upon medicating bisphosphonate for an elderly person: Preservation therapy and responses for Stage 0 of bisphosphonate-related osteonecrosis of jaw. Eur J Dent 2017; 11:258-263. [PMID: 28729804 PMCID: PMC5502576 DOI: 10.4103/ejd.ejd_264_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This case report aimed to report the progress of preservation therapy and response of symptoms and signs for Stage 0 of bisphosphonate-related osteonecrosis of jaw (BRONJ). A 68-year-old female was recognized having a tooth at the left upper first molar fracture upon medicating bisphosphonate (BP) in 2007. At that time, the extraction of the tooth was an absolute contraindication. Therefore, we performed preservation therapy. We observed the symptoms and signs every month. After 5 months, swelling and redness in the entire first molar tooth were seen and fistula formed partly. Bone exposure was not seen. We administrated antibiotics immediately. As a result, symptoms disappeared. On April 10, 2009, the patient visited us as she felt a sense of incongruity in the lower left first and second molar teeth. Clinically, there were no symptoms of pain. However, we observed the radiolucent finding in about 5 mm diameter at apical position by X-ray photography; we considered a possibility of Stage 0 for BRONJ. We immediately administered medicine for 5 days and the symptoms disappeared. At present, no inflammation with signs and symptoms at the upper left first molar and lower left first, second molar parts is shown. We performed preservation therapy for tooth fracture case medicating of BP. Immediate responses for inflammation and symptoms of the Stage 0 of BRONJ have led to success. Hence, dentists should perform regular clinical observation, and enough education to the patient for BRONJ is necessary.
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Affiliation(s)
- Noriko Suzuki
- Department of Geriatric Dentistry, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Hitoshi Oguchi
- Department of Geriatric Dentistry, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Yu Yamauchi
- Department of Geriatric Dentistry, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Yasuyo Karube
- Department of Geriatric Dentistry, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Yukimi Suzuki
- Department of Geriatric Dentistry, School of Dental Medicine, Tsurumi University, Yokohama, Japan
| | - Noriyasu Hosoya
- Department of Endodontology, School of Dental Medicine, Tsurumi University, Yokohama, Japan
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Maluf G, Caldas RJ, Silva Santos PS. Use of Leukocyte- and Platelet-Rich Fibrin in the Treatment of Medication-Related Osteonecrosis of the Jaws. J Oral Maxillofac Surg 2017; 76:88-96. [PMID: 28675810 DOI: 10.1016/j.joms.2017.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
Lesions associated with medication-related osteonecrosis of the jaws (MRONJ) are refractory to different treatment approaches. Hence, auxiliary approaches capable of improving patient outcomes should be explored. Leukocyte- and platelet-rich fibrin (LPRF) is a second-generation platelet concentrate (natural autologous fibrin matrix). It shows anti-infectious activity through immune regulation and accelerates the angiogenesis and multiplication of fibroblasts and osteoblasts; in consequence, it stimulates soft tissue healing and prevents exposure of the alveolar bone in the oral cavity. This report describes 2 cases involving women with breast cancer who were being treated with zoledronic acid and exhibited advanced MRONJ. In case 1, MRONJ developed in the maxilla after dental extraction; in case 2, it was assumed that MRONJ arose spontaneously in the mandible because no other risk factors could be detected. These cases were managed with surgical resection of the necrotic bone followed by placement of an LPRF membrane. Complete wound healing and intact mucosal cover were achieved. At clinical and tomographic follow-up after 2 years, there were no oral lesions or complaints. Therefore, this could be a noninvasive, quick, and alternative approach to manage bone exposure. The LPRF membrane contributes to a successful outcome and acts as a physical barrier against micro-organisms, thus preventing secondary infections.
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Affiliation(s)
- Gustavo Maluf
- MSc and PhD Student, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP, Brazil
| | - Rogério Jardim Caldas
- MSc and PhD Student, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP, Brazil
| | - Paulo Sérgio Silva Santos
- Assistant Professor, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP, Brazil.
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El-Rabbany M, Sgro A, Lam DK, Shah PS, Azarpazhooh A. Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis. J Am Dent Assoc 2017; 148:584-594.e2. [PMID: 28527518 DOI: 10.1016/j.adaj.2017.04.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/01/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The effectiveness of management strategies used for the treatment of medication-related osteonecrosis of the jaw (MRONJ) remains poorly understood. The authors evaluated systematically the effectiveness of the various treatment modalities used for MRONJ. TYPES OF STUDIES REVIEWED The authors conducted a comprehensive search of MEDLINE, Embase, the Cochrane Library, and Scopus to identify randomized controlled trials, nonrandomized controlled trials, and prospective cohort studies to evaluate comparatively the effectiveness of management strategies for the treatment of MRONJ. The authors conducted the identification of eligible studies in duplicate and synthesized the extracted data by means of a meta-analysis, when feasible. RESULTS The authors found 13 studies with a medium-to-high risk of bias that met the inclusion criteria of this review. The authors found that, compared with medical treatment of local antimicrobials with or without systemic antimicrobials, the study investigators associated surgical treatment with higher odds of complete resolution of the condition (2 studies; 76 participants; unadjusted odds ratio, 3.55; 95% confidence interval, 1.12 to 11.19). The effectiveness of other therapies, such as bisphosphonate drug holidays, teriparatide, and hyperbaric oxygen, was uncertain. CONCLUSIONS AND PRACTICAL IMPLICATIONS On the basis of the results of an unadjusted analysis, the results of the studies that were deemed to be medium to low quality and to have medium-to-low statistical power suggested that there are higher odds of resolving MRONJ with surgical treatment compared with medical treatment. High-quality research is required for conclusive statements to be made regarding treatment strategies for management of MRONJ.
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Voss PJ, Matsumoto A, Alvarado E, Schmelzeisen R, Duttenhöfer F, Poxleitner P. Treatment of stage II medication-related osteonecrosis of the jaw with necrosectomy and autologous bone marrow mesenchymal stem cells. Odontology 2017; 105:484-493. [PMID: 28220264 DOI: 10.1007/s10266-017-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/19/2016] [Indexed: 02/07/2023]
Abstract
Treatment strategies for medication-related osteonecrosis of the jaw (MRONJ) remain controversial. Although the AAOMS suggests a conservative approach, a surgical management with necrosectomy is often required when conservative management has failed. Moreover, recent studies have shown promising results using an early stage surgical treatment. Over the past decade, cell-based bone regeneration utilizing bone marrow mesenchymal stem cells (MSCs) received increased attention. MSCs are known to promote wound healing and induce new bone formation in compromised tissue. Accordingly, the aim of this study was to assess the role of MSCs in the management of MRONJ. This study included 6 patients referred to our department with the diagnosis of MRONJ. Upon informed consent, the patients underwent surgical resection of necrotic bone followed by MSCs grafting. The MSCs were separated from bone marrow cells aspirated from the iliac crest using a bone marrow aspirate concentrate system. The MSCs were grafted into the defect with autologous thrombin and the defect was covered with a collagen membrane. In all cases, bony edges were rounded and the wound was closed using a three-layered technique. In the follow-up from 12 to 54 months, all patients including those who had impaired conditions, sepsis, or pathological fracture, showed satisfactory healing with no signs of wound infection. This pilot study indicated that surgical management in combination with MSCs transplantation seems to be a promising treatment modality in the therapy of MRONJ.
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Affiliation(s)
- Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Germany
| | - Akihiko Matsumoto
- Section of Oral and Maxillofacial Surgery, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Esteban Alvarado
- Section of Orthodontics and Maxillofacial Surgery, Latinamerican University of Science and Technology, 100 metros sur del Periódico La República, San José, Barrio Tournón, Costa Rica
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Germany
| | - Fabian Duttenhöfer
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Germany
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Bermúdez-Bejarano EB, Serrera-Figallo MÁ, Gutiérrez-Corrales A, Romero-Ruiz MM, Castillo-de-Oyagüe R, Gutiérrez-Pérez JL, Machuca-Portillo G, Torres-Lagares D. Analysis of different therapeutic protocols for osteonecrosis of the jaw associated with oral and intravenous bisphosphonates. Med Oral Patol Oral Cir Bucal 2017; 22:e43-e57. [PMID: 27918742 PMCID: PMC5217496 DOI: 10.4317/medoral.21477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/11/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction Chemotherapy-associated osteonecrosis of the jaw caused by bisphosphonates is an exposure of necrotic bone with more than eight weeks of evolution that is attributable to bisphosphonates and no prior radiation therapy. Its etiopathogenesis remains unknown, although there are two hypotheses that may explain it: the drug’s mechanism of action, and the risk factors that can lead to osteonecrosis. There is a wide range of treatment options for managing chemotherapy-associated osteonecrosis of the jaw, from conservative treatments to surgical procedures of varying levels of invasiveness, which are sometimes supplemented with adjuvant therapies. Objectives The objective of this article is to group the therapeutic options for osteonecrosis of the jaw (ONJ) into seven different protocols and to evaluate their effectiveness in relation to stage of ONJ. Material and Methods A literature review was carried out in PubMed following the PRISMA criteria. A total of 47 were collected after compiling a series of variables that define ONJ, applied treatments, and the clinical results obtained. Results and Discussion The 47 articles selected have a low to average estimated risk of bias and are of moderate to good quality. According to the data obtained, Protocol 3 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies) is the most favorable approach for ONJ lesions caused by oral bisphosphonates. For lesions caused by intravenous bisphosphonates, Protocol 2 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and no adjuvant therapies) is the best approach. When comparing the different stages of ONJ, Protocol 1 (conservative treatment, clinical and radiological follow-up) promotes better healing of Stage 1 ONJ lesions caused by orally administered bisphosphonates, and Protocol 3 is recommended for Stage II. For ONJ lesions attributable to intravenous bisphosphonates, Protocol 7 (conservative treatment, clinical and radiological follow-up, and adjuvant therapies) provides the best results in Stage 0; in Stages I, II, and III, Protocol 1 gives better results. Key words:Bisphosphonates, bronj, therapeutic protocol, clinical result.
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Bermúdez-Bejarano EB, Serrera-Figallo MÁ, Gutiérrez-Corrales A, Romero-Ruiz MM, Castillo-de-Oyagüe R, Gutiérrez-Pérez JL, Torres-Lagares D. Prophylaxis and antibiotic therapy in management protocols of patients treated with oral and intravenous bisphosphonates. J Clin Exp Dent 2017; 9:e141-e149. [PMID: 28149479 PMCID: PMC5268104 DOI: 10.4317/jced.53372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 10/01/2016] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Osteonecrosis of the jaw (MRONJ) linked to bisphosphonate treatment has specific characteristics that render its therapeutic management challenging for clinicians. Poor response to standard treatment makes it essential to take special precautions when treating this type of disease; therefore, antibiotic prophylaxis and/or antibiotic therapy have been proposed as effective and helpful tools in these situations. OBJECTIVES This article seeks to assess published evidence in order to evaluate the different protocols used for antibiotic prophylaxis and/or antibiotic therapy in the general context of patients treated with bisphosphonates. MATERIAL AND METHODS A literature review of the last 10 years was carried out in PubMed using the following keywords: "antibiotic prophylaxis and osteonecrosis," "bisphosphonates AND osteonecrosis AND dental management," "bisphosphonate AND osteonecrosis AND antibiotic prophylaxis AND oral surgery." A total of 188 articles were obtained, of which 18 were ultimately selected. RESULTS AND DISCUSSION In patients treated with oral and intravenous bisphosphonates without chemotherapy-associated osteonecrosis of the jaw, antibiotic prophylaxis prior to oral surgery is an important tool to avoid osteonecrosis and promote healing of the affected area. If the patient previously exhibited chemotherapy-associated osteonecrosis after tooth extraction, antibiotic prophylaxis is indicated to prevent recurrent osteonecrosis and promote healing of the extraction site. If chemotherapy-associated osteonecrosis is already present, antibiotic therapy is a vital part of conservative management to reduce the symptomatology of MRONJ and keep it from worsening. Finally, a lack of clinical data and randomized controlled trials makes it difficult to choose the most appropriate protocol for the various clinical situations studied. Key words:Bisphosphonates, antibiotic prophylaxis, maxillary osteonecrosis, antibiotic treatment.
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Affiliation(s)
| | - María-Ángeles Serrera-Figallo
- Associate Professor. Integrated Dentistry and Patients with Special Diseases. School of Dentistry. University of Seville
| | | | | | - Raquel Castillo-de-Oyagüe
- Professor of Prostheses. Department of Stomatology. School of Dentistry. Complutense University of Madrid
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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: 150] [Impact Index Per Article: 21.4] [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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Pichardo SE, Kuijpers SC, van Merkesteyn JR. Bisphosphonate-related osteonecrosis of the jaws: Cohort study of surgical treatment results in seventy-four stage II/III patients. J Craniomaxillofac Surg 2016; 44:1216-20. [DOI: 10.1016/j.jcms.2016.06.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/09/2016] [Accepted: 06/16/2016] [Indexed: 11/24/2022] Open
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Rodriguez-Lozano FJ, Oñate-Sánchez RE. Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents. Med Oral Patol Oral Cir Bucal 2016; 21:e595-600. [PMID: 27475683 PMCID: PMC5005097 DOI: 10.4317/medoral.20980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
Background The clinical management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bisphosphonates and other antiresorptive agents is subject to controversy. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed guidelines for the correct management of the disorder which are revised and updated by a panel of experts. Material and Methods The present systematic review analyzes the different treatments currently used to treat this clinical condition, based on the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement published in 2009. An electronic Medline search was made of the PubMed database, covering the period 2006-2014. The last search date was 31 December 2014. Results A total of 29 articles were selected from the initial search according to the different drugs implicated in the appearance of osteonecrosis; the treatment modality used according to the stage of the disease; and the recorded success rate. Conclusions It is currently still recommended that the management of MRONJ should be decided according to the stage of the disease – conservative treatment being preferred in early stages without symptoms, while surgical management is preferred in the case of bone exposure with symptoms. Key words:Osteonecrosis, medication, bisphosphonates, treatments, review
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Affiliation(s)
- F-J Rodriguez-Lozano
- Clínica Odontológica Universitaria, Unidad Pacientes Especiales y Gerodontología, University of Murcia, IMIB-Arrixaca. Morales Meseguer Hospital, Avda. Marqués de los Vélez s/n, 30007- Murcia, Spain,
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Abstract
Bisphosphonates are widely used for treatment or prevention of bone diseases characterized by high osteoclastic activity. Among the oral medicines used to treat osteoporosis, alendronate has been often used. Despite of the low rate of complications on its use, cases of osteonecrosis of the jaw have been reported on literature after tooth extractions. The main symptoms include pain, tooth mobility, swelling, erythema, and ulceration. The risk factors related to osteonecrosis of the jaw associated with bisphosphonate are exposition time to the medicine, routes of administration, and oral surgical procedures performed. The aim of this work is to report a case of a patient showing osteonecrosis of the jaw associated with the use of oral bisphosphonates after tooth extractions. The patient was treated through the suspension of the alendronate with the removal of the necrotic tissue and the foci of infection. After a year's follow-up, the patient showed no recurrence signs. From the foregoing, the interruption of the alendronate use and the surgical treatment associated to antibiotic therapy showed effective on the patient's treatment.
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Does Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography Facilitate Treatment of Medication-Related Osteonecrosis of the Jaw? J Oral Maxillofac Surg 2016; 74:945-58. [DOI: 10.1016/j.joms.2015.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 12/31/2022]
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Pichardo SEC, de Roos P, van Merkesteyn JPR. 'Autoreconstruction' of the Mandible-Report of a Case. Dent J (Basel) 2016; 4:dj4020009. [PMID: 29563451 PMCID: PMC5851267 DOI: 10.3390/dj4020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 11/16/2022] Open
Abstract
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) was first mentioned in the literature in 2003. Since then, several reports have been published referring to this disease. The etiology of BRONJ still remains unclear. The treatment of BRONJ also remains a topic of discussion between those who are in favor of a conservative treatment and those who are convinced that surgical treatment gives the best results. In this case report, a patient is presented with BRONJ in the mandible which has been treated surgically in combination with antibiotic treatment. During surgery it appeared that a large part of the jaw was sequestrated full-thickness with, at the same time, formation of a substantial amount of subperiosteal bone that was formed around the BRONJ, supporting the sequestrated part of the mandible and, after sequestrectomy, serving as a neo-mandible. This case shows the capacity of the jawbone despite bisphosphonate use to regenerate itself.
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Affiliation(s)
- Sarina E C Pichardo
- Department of Oral & Maxillofacial Surgery (Chair: Prof. Dr. JPR van Merkesteyn), Leiden University Medical Center, P.O. Box 9600, 2300 RC LEIDEN, The Netherlands.
| | - Pieter de Roos
- Department of Oral & Maxillofacial Surgery, IJsselland Hospital, Capelle aan den Ijssel.
| | - J P Richard van Merkesteyn
- Department of Oral & Maxillofacial Surgery (Chair: Prof. Dr. JPR van Merkesteyn), Leiden University Medical Center, P.O. Box 9600, 2300 RC LEIDEN, The Netherlands.
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Pichardo SEC, van Merkesteyn JPR. Evaluation of a surgical treatment of denosumab-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:272-8. [PMID: 27234854 DOI: 10.1016/j.oooo.2016.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/08/2016] [Accepted: 03/04/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Denosumab, a monoclonal antibody, is a relatively new antiresorptive agent that has recently shown a serious adverse effect: denosumab-related osteonecrosis of the jaws (DRONJ). The purpose of this study was to retrospectively observe the efficacy of the combined surgical and antimicrobial treatment of DRONJ. STUDY DESIGN In this case series, all patients with osteonecrosis that occurred after starting treatment with denosumab, were treated with surgery and antimicrobial treatment and followed up. The primary outcome was healing of the jaw. For patient characterization, secondary variables, such as clinical features, denosumab use, dental history (including luxation), and duration of complaints, were studied. RESULTS Eleven patients met the criteria to be included in this study. Nine patients experienced healing within 4 weeks after surgery. Two patients were not cured and died as a result of their underlying disease. In all patients, a dental focus was found. Six patients had been treated only with denosumab, and five had also been treated with bisphosphonates. CONCLUSIONS We were able to achieve healing in 9 of the 11 patients with DRONJ. Our treatment protocol showed promising results; however, further research is needed.
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Affiliation(s)
- Sarina E C Pichardo
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J P Richard van Merkesteyn
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Silva LF, Curra C, Munerato MS, Deantoni CC, Matsumoto MA, Cardoso CL, Curi MM. Surgical management of bisphosphonate-related osteonecrosis of the jaws: literature review. Oral Maxillofac Surg 2015; 20:9-17. [PMID: 26659615 DOI: 10.1007/s10006-015-0538-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 12/01/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been performed in an attempt to increase healing rates of the affected cases. This literature review aimed to identify clinical studies of surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in order to assess their surgical treatment modalities, outcome and the follow-up. METHODS A search in the PubMed (Medline) database using specific terms and/or phrases as "bisphosphonate-related osteonecrosis" or "jaw osteonecrosis", and "surgical treatment" or "surgical management" was conducted in order to identify clinical trials and cases of surgical treatment of BRONJ. The review search covered the time period from 2004 to 2014. All studies identified in the search were selected according to the inclusion criteria. Relevant information was recorded according to the following items: author, year, number of patients, BRONJ clinical stage, surgical treatment modality, clinical success, and follow-up. RESULTS The initial database search yielded 345 titles. After filtering, 67 abstracts were selected culminating in 67 full text articles. A variety of surgical approach was found in this review: debridement, sequestrectomy bone resection, and bone reconstruction. Adjunctive therapies included hyperbaric oxygen, laser therapy, growth factors, and ozone. CONCLUSION Although there are many indexed studies about BRONJ, well-documented reports concerning surgical therapeutically techniques are scarce, resulting from a lack of well-established protocols. Considerable differences were found regarding sample size, surgical treatment modalities and outcomes. Clinical studies with larger number of patients and longer follow-up are required to provide best information for each surgical treatment modality and its outcomes.
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Affiliation(s)
| | - Cláudia Curra
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil
| | - Marcelo Salles Munerato
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil.
| | - Carlos Cesar Deantoni
- Department of Oral and Maxillofacial Surgery, Universidade do Sagrado Coração, Rua Irmã Arminda 10-50, CEP: 17011-160, Bauru, São Paulo, Brazil
| | | | - Camila Lopes Cardoso
- Universidade do Sagrado Coração, Bauru, SP, Brazil.,Department of Stomatology, Hospital Santa Catarina, Sao Paulo, Brazil
| | - Marcos Martins Curi
- Universidade do Sagrado Coração, Bauru, SP, Brazil.,Department of Stomatology, Hospital Santa Catarina, Sao Paulo, Brazil
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Aghaloo T, Hazboun R, Tetradis S. Pathophysiology of Osteonecrosis of the Jaws. Oral Maxillofac Surg Clin North Am 2015; 27:489-96. [PMID: 26412796 DOI: 10.1016/j.coms.2015.06.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Osteonecrosis of the jaw (ONJ) is a multifactorial disease in patients with primary or metastatic bone malignancy or osteoporosis undergoing systemic antiresorptive therapy, where pathophysiology has not yet been fully determined. The staging of ONJ is based on severity of symptoms and extent of clinical and radiographic findings. Treatment strategies range from conservative local wound care to aggressive resective surgery of all necrotic bone. The first ONJ cases were reported in 2003 and 2004, and although significant progress has been made in our understanding of the disease, much more work needs to be done to completely explain its pathophysiology.
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Affiliation(s)
- Tara Aghaloo
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA.
| | - Renna Hazboun
- Section of Special Patient Care, Division of Advanced Prosthodontics and Section of Restorative Dentistry, Division of Regenerative and Constitutive Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA
| | - Sotirios Tetradis
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA; Molecular Biology Institute, UCLA, Los Angeles, CA 90095, USA
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Matsuo A, Hamada H, Takahashi H, Okamoto A, Kaise H, Chikazu D. Evaluation of dental implants as a risk factor for the development of bisphosphonate-related osteonecrosis of the jaw in breast cancer patients. Odontology 2015; 104:363-71. [PMID: 25956267 DOI: 10.1007/s10266-015-0207-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 03/30/2015] [Indexed: 02/06/2023]
Abstract
It remains unclear whether dental implants are a risk factor for the development of bisphosphonate-related osteonecrosis of the jaw (BRONJ). We retrospectively evaluated the status of dental implants in patients given intravenous bisphosphonates (BPs) in a breast cancer cohort to elucidate the risk for BRONJ at the implant site. We established a BRONJ oral monitoring program for 247 breast cancer patients given intravenous BP in our institution. The 3-year cumulative incidence rate was determined. The systemic and local risk factors of 44 patients who completed comprehensive oral examinations were evaluated by logistic regression analysis. The 3-year cumulative incidence rate of the 247 patients was 0.074 % (8/247, 95 % CI 0.0081-0.014). In the 44 orally examined patients, 6 (13.6 %: 6/44) had dental implants. Of these 6 patients, 1 developed BRONJ at the implant site. There were no significant differences in the age, total BP treatment period, number of residual teeth, time of regular oral monitoring, oral hygiene level, or dental implant insertion. Although a case of ONJ was identified, dental implants which were inserted before intravenous BP administration were not a risk factor for the development of ONJ in breast cancer patients.
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Affiliation(s)
- Akira Matsuo
- Department of Oral and Maxillofacial Surgery, Ibaraki Medical Center, Tokyo Medical University, 3-20-1 Chuo, Amimachi, Inashikigun, Ibaraki, 300-3095, Japan.
| | - Hayato Hamada
- Department of Oral and Maxillofacial Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hidetoshi Takahashi
- Department of Oral and Maxillofacial Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ayako Okamoto
- Department of Oral and Maxillofacial Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroshi Kaise
- Department of Breast Oncology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Daichi Chikazu
- Department of Oral and Maxillofacial Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Barba-Recreo P, Del Castillo Pardo de Vera JL, Georgiev-Hristov T, Ruiz Bravo-Burguillos E, Abarrategi A, Burgueño M, García-Arranz M. Adipose-derived stem cells and platelet-rich plasma for preventive treatment of bisphosphonate-related osteonecrosis of the jaw in a murine model. J Craniomaxillofac Surg 2015; 43:1161-8. [PMID: 26027865 DOI: 10.1016/j.jcms.2015.04.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 04/02/2015] [Accepted: 04/30/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The main challenge in treating bisphosphonate-related osteonecrosis of the jaw (BRONJ) is the absence of an effective established treatment. We aimed to compare different potentially preventive treatments for BRONJ after dental extractions in zoledronic acid (ZA)-treated animals. We studied the local application of different combinations of adipose-derived stem cells (ASCs) with or without previous stimulation with bone morphogenetic protein 2 (BMP-2) and platelet-rich plasma (PRP) in rats. MATERIAL AND METHODS Fifty-six male Wistar rats were treated with ZA for 9 weeks. Dental extractions were performed in the eighth week, and the animals were divided into 4 groups. In group 1 (n = 14), alveolar coverage with mucoperiosteal flap was performed. In group 2 (n = 14), PRP was applied over the sockets and covered with the flap. In group 3 (n = 15), allogeneic ASCs with PRP were applied and covered with the flap. In group 4 (n = 13), animals were treated with ASCs cultured with BMP-2, PRP, and flap coverage. Histologic, fluorescence, and radiologic studies of the maxillae were performed. RESULTS ASC-treated animals showed lower frequency of osteonecrosis (14% vs 50%, p = 0.007) and greater bone turnover (p = 0.024) and osteoclast count (p = 0.045) than those not receiving the ASC treatment. CONCLUSIONS In this high-risk model, ASC-based treatments seem to prevent BRONJ more effectively than mucosal flap with or without PRP. The combination of ASCs and PRP appears to be synergistic, and the addition of BMP-2 could further improve the results.
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Affiliation(s)
- Paula Barba-Recreo
- Department of Oral and Maxillofacial Surgery (Head: Miguel Burgueño), Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain.
| | - Jose Luis Del Castillo Pardo de Vera
- Department of Oral and Maxillofacial Surgery (Head: Miguel Burgueño), Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Tihomir Georgiev-Hristov
- Cell Therapy Laboratory (Head: Damián García Olmo), Instituto de Investigación Sanitario Fundación Jiménez Díaz, Avda. Reyes Católicos 2, 28040 Madrid, Spain; Department of General Surgery, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos 2, 28040 Madrid, Spain
| | | | - Ander Abarrategi
- Cellular Biotechnology Unit, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2.200, 28220 Majadahonda, Spain; Haematopoietic Stem Cell Laboratory, Cancer Research UK, 44 Lincoln's Inn Fields, London WC2A 3LY, United Kingdom
| | - Miguel Burgueño
- Department of Oral and Maxillofacial Surgery (Head: Miguel Burgueño), Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain; Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, C/ Arzobispo Morcillo s/n, 28029 Madrid, Spain
| | - Mariano García-Arranz
- Cell Therapy Laboratory (Head: Damián García Olmo), Instituto de Investigación Sanitario Fundación Jiménez Díaz, Avda. Reyes Católicos 2, 28040 Madrid, Spain; Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, C/ Arzobispo Morcillo s/n, 28029 Madrid, Spain
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Treatment strategies and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) with characterization of patients: a systematic review. Int J Oral Maxillofac Surg 2015; 44:568-85. [DOI: 10.1016/j.ijom.2015.01.026] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/28/2015] [Accepted: 01/30/2015] [Indexed: 11/22/2022]
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Voss PJ, Stoddart M, Ziebart T, Zeiter S, Nelson K, Bittermann G, Schmelzeisen R, Poxleitner P. Zoledronate induces osteonecrosis of the jaw in sheep. J Craniomaxillofac Surg 2015; 43:1133-8. [PMID: 26154396 DOI: 10.1016/j.jcms.2015.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The treatment of bisphosphonate-related osteonecrosis of the jaw has become routine in maxillofacial hospitals. However, the etiopathology has not yet been fully understood. The aim of this study was to develop a large animal model for medication-related osteonecrosis of the jaw (MRONJ). MATERIAL AND METHODS Eight Swiss mountain sheep were randomly assigned into two groups. Group I received 0.075 mg/kg zoledronate (ZOL) intravenously every third week for 16 weeks. After 16 weeks, extraction of the first and second lower left premolar was performed. Group II underwent surgery and no ZOL was administered. After surgery, Group I continued to receive ZOL infusions; after 16 weeks, all animals were euthanized. The jaw bones were investigated macroscopically, radiographically (computed tomography) and histologically. RESULTS Osteonecrosis of the jaw was observed at all extraction sites in all the animals receiving ZOL, and at none of the sites in animals without ZOL. All ZOL-treated animals spontaneously developed exposed bone lesions in the oral cavity at sites where no surgical intervention was performed. CT imaging shows persistent alveolar extraction sockets 16 weeks after surgery in all animals of the ZOL-group, and healed alveolar extraction sockets in non-ZOL-treated animals. CONCLUSION Sheep treated with ZOL reproducibly demonstrated osteonecrosis of the jaw after tooth extraction, and spontaneous development of exposed bone in the oral cavity at sites where no manipulation was performed. This animal model can be used for further research in the fields of BP-ONJ etiopathology, oral implantology, bone and fracture healing and periodontology.
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Affiliation(s)
- Pit Jacob Voss
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, (Head: Prof. Dr. R. Schmelzeisen), Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany.
| | - Martin Stoddart
- AO Research Institute Davos, (Head: Prof. Dr. G. Richards), Clavadeler Str. 8, 7270 Davos Platz, Switzerland.
| | - Thomas Ziebart
- Department of Oral and Maxillofacial Surgery, University Hospital Mainz, (Head: Prof. Dr. W. Wagner), Augustusplatz 2, 55131 Mainz, Germany.
| | - Stephan Zeiter
- AO Research Institute Davos, (Head: Prof. Dr. G. Richards), Clavadeler Str. 8, 7270 Davos Platz, Switzerland.
| | - Katja Nelson
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, (Head: Prof. Dr. R. Schmelzeisen), Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany.
| | - Gido Bittermann
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, (Head: Prof. Dr. R. Schmelzeisen), Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany.
| | - Rainer Schmelzeisen
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, (Head: Prof. Dr. R. Schmelzeisen), Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany.
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, (Head: Prof. Dr. R. Schmelzeisen), Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany; AO Research Institute Davos, (Head: Prof. Dr. G. Richards), Clavadeler Str. 8, 7270 Davos Platz, Switzerland.
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Abstract
BACKGROUND Bisphosphonates (BP) are used in the treatment of severe osteoporosis and metastasis of malignant diseases. A possible relationship between the occurrence of osteonecrosis of the jaw and BP therapy was first described in 2003. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is difficult to treat. In some cases the condition of the patients is so compromised that only minimally invasive surgery is possible. Histopathologically, osteonecrosis shows the features of chronic sequestered osteomyelitis, which can be found in different areas of the upper and lower jaw. Sometimes extensive resections of the jaw are necessary. Thus, BRONJ can cause mutilation, impairment of function and esthetics in the orofacial system and, thereby, compromise the life quality of the patients. Triggering factors are often tooth extraction without surgical plastic wound closure of the alveoli, but can also be associated with bruises from denture or other minor wounds. OBJECTIVES The purpose of this article is to present results from our own patient collective, including therapy regime, success rate, and therapy recommendations. METHODS The patient populations at three German hospitals were analyzed using a standard questionnaire. The patients in the study group, entered into a follow-up system for early detection of possible BRONJ, were evaluated for treatement outcome. RESULTS The success rate for prophylactic surgery in asymptomatic patients was very high at 96 %. In the group with symptomatic BRONJ, the outcome was significantly lower (76.4 %). CONCLUSIONS Because of the complex symptoms, close cooperation between oncologists, dentists, and maxillofacial surgeons is required in the treatment of BRONJ. Before starting therapy with bisphosphonates and during the therapy, dental treatment and monitoring of the patient' oral health is necessary.
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Spanou A, Lyritis GP, Chronopoulos E, Tournis S. Management of bisphosphonate-related osteonecrosis of the jaw: a literature review. Oral Dis 2015; 21:927-36. [PMID: 25732104 DOI: 10.1111/odi.12333] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/08/2014] [Accepted: 02/24/2015] [Indexed: 12/31/2022]
Abstract
Osteonecrosis of the jaw (ONJ) is a serious side effect of bisphosphonate use in patients with osteoporosis, Paget's disease, hypercalcemia of malignancy, metastatic bone disease and multiple myeloma, although recently this complication has also been reported in patients under non-bisphosphonate medication, such as denosumab and bevacizumab. The occurrence of ONJ is higher in oncology patients treated with high-dose iv bisphosphonates than in osteoporosis patients treated with oral bisphosphonates. Although multiple hypotheses have been proposed, the exact pathogenic mechanism of ONJ still remains unclear. As treatment protocols based on randomized controlled trials (RCTs) do not exist, we critically reviewed the existing data concerning the management of bisphosphonate-related osteonecrosis of the jaw, including the most recent data for the use of teriparatide and hyperbaric oxygen.
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Affiliation(s)
- A Spanou
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece
| | - G P Lyritis
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece
| | - E Chronopoulos
- Postgraduate Course on Metabolic Bone Disease, Faculty of Medicine, University of Athens, Athens, Greece.,2nd Orthopaedic Department, Konstantopoulion Hospital, University of Athens, Athens, Greece
| | - S Tournis
- Laboratory for Research of the Musculoskeletal System 'Th. Garofalidis', Medical School, KAT Hospital, University of Athens, Athens, Greece
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Pabst AM, Krüger M, Ziebart T, Jacobs C, Sagheb K, Walter C. The influence of geranylgeraniol on human oral keratinocytes after bisphosphonate treatment: An in vitro study. J Craniomaxillofac Surg 2015; 43:688-95. [PMID: 25913629 DOI: 10.1016/j.jcms.2015.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 03/13/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022] Open
Abstract
This in vitro study analyzed the influence of geranylgeraniol (GGOH) on human oral keratinocytes (HOK) after exposure to bisphosphonates. HOK were incubated with four different bisphosphonates (clodronate, ibandronate, pamidronate, zoledronate) in two experimental set-ups: with and without GGOH. MTT and PrestoBlue assays were used to analyze HOK cell viability. HOK migration ability was examined with Boyden and Scratch assays, and Tunel and ToxiLight assays were used to detect the HOK apoptosis rate. No significant differences between the experimental set-ups, with and without GGOH, could be found for clodronate (p each >0.3). For the nitrogen-containing bisphosphonates, negative effects could be shown in the experimental set-ups without GGOH in all assays. In the GGOH experimental set-ups, the levels of HOK cell viability were significantly increased (MTT: p each ≤0.001; PrestoBlue: p each ≤0.012). The HOK migration ability was also greater (Boyden: p each <0.001; Scratch: p each ≤0.015). Regarding the apoptosis rate, reduced numbers of apoptotic HOK in the Tunel assay (p each <0.001) and decreased adenylate kinase release in the ToxiLight assay (p each ≤0.002) were observed. GGOH reversed the negative effects of bisphosphonates on HOK. These findings provide evidence that GGOH could be a promising treatment option for BP-ONJ.
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Affiliation(s)
- Andreas Max Pabst
- Department of Oral and Maxillofacial Surgery (Head: Univ.-Prof. Dr. Dr. W. Wagner), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany.
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery (Head: Univ.-Prof. Dr. Dr. W. Wagner), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Thomas Ziebart
- Department of Oral and Maxillofacial Surgery (Head: Univ.-Prof. Dr. Dr. W. Wagner), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Collin Jacobs
- Department of Orthodontics (Head: Univ.-Prof. Dr. Dr. H. Wehrbein), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Keyvan Sagheb
- Department of Oral and Maxillofacial Surgery (Head: Univ.-Prof. Dr. Dr. W. Wagner), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Christian Walter
- Department of Oral and Maxillofacial Surgery (Head: Univ.-Prof. Dr. Dr. W. Wagner), University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
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Pabst AM, Krüger M, Ziebart T, Jacobs C, Walter C. Isoprenoid geranylgeraniol: the influence on cell characteristics of endothelial progenitor cells after bisphosphonate therapy in vitro. Clin Oral Investig 2015; 19:1625-33. [DOI: 10.1007/s00784-014-1394-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/18/2014] [Indexed: 01/29/2023]
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Rugani P, Acham S, Kirnbauer B, Truschnegg A, Obermayer-Pietsch B, Jakse N. Stage-related treatment concept of medication-related osteonecrosis of the jaw—a case series. Clin Oral Investig 2014; 19:1329-38. [DOI: 10.1007/s00784-014-1384-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 12/02/2014] [Indexed: 11/28/2022]
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Matsuo A, Hamada H, Kaise H, Chikazu D, Yamada K, Kohno N. Characteristics of the early stages of intravenous bisphosphonate-related osteonecrosis of the jaw in patients with breast cancer. Acta Odontol Scand 2014; 72:656-63. [PMID: 24521290 DOI: 10.3109/00016357.2014.887772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The clinical features of the early stages of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients with breast cancer remain unclear. A retrospective cohort study was conducted of patients with breast cancer who received intravenous bisphosphonate (BP) treatment in a single center in order to clarify the status of the early stages of BRONJ. MATERIALS AND METHODS A BRONJ oral monitoring program was established in 247 breast cancer patients given intravenous BP treatment at the institution. The differences in age, BP treatment period, number of remaining teeth, oral hygiene status, presence of regular oral monitoring and the existence of suspected BRONJ (stage 0) among eight BRONJ and 36 non-BRONJ subjects who completed oral examinations were then compared. RESULTS BRONJ was observed in 0.4% of subjects on the first visit to the oral surgery clinic and in 3.2% of subjects during the follow-up period. Logistic regression analysis revealed that the odds ratio for identifying patients with BRONJ during follow-up by the presence of stage 0 at first visit was 24.0 (95% confidence interval [CI] = 3.6-161.7). The area under the receiver operating characteristic curve for identifying subjects with BRONJ by the presence of stage 0 was 0.82 (95% CI = 0.63-1.00). CONCLUSION The results suggest that patients with stage 0 BRONJ on the first visit may progress to advanced BRONJ during the follow-up period. The oral monitoring program may contribute to the early detection of BRONJ.
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Rupel K, Ottaviani G, Gobbo M, Contardo L, Tirelli G, Vescovi P, Di Lenarda R, Biasotto M. A systematic review of therapeutical approaches in bisphosphonates-related osteonecrosis of the jaw (BRONJ). Oral Oncol 2014; 50:1049-57. [DOI: 10.1016/j.oraloncology.2014.08.016] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/21/2014] [Accepted: 08/26/2014] [Indexed: 11/28/2022]
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Carlson ER. Response to the Letter to the Editor. J Oral Maxillofac Surg 2014; 72:1641-2. [DOI: 10.1016/j.joms.2014.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 10/24/2022]
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Bedogni A, Fedele S, Bedogni G, Scoletta M, Favia G, Colella G, Agrillo A, Bettini G, Di Fede O, Oteri G, Fusco V, Gabriele M, Ottolenghi L, Valsecchi S, Porter S, Petruzzi M, Arduino P, D’Amato S, Ungari C, Fung Polly PL, Saia G, Campisi G. Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease. Br J Oral Maxillofac Surg 2014; 52:603-8. [PMID: 24856927 DOI: 10.1016/j.bjoms.2014.04.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
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Longo F, Guida A, Aversa C, Pavone E, Di Costanzo G, Ramaglia L, Ionna F. Platelet rich plasma in the treatment of bisphosphonate-related osteonecrosis of the jaw: personal experience and review of the literature. Int J Dent 2014; 2014:298945. [PMID: 25013411 PMCID: PMC4071853 DOI: 10.1155/2014/298945] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/19/2014] [Indexed: 11/18/2022] Open
Abstract
Bisphosphonates (BPs) are a class of synthetic drugs commonly used to treat bone metastasis and various bone diseases that cause osseous fragility (such as osteoporosis). Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a common complication in patients who received BPs, especially intravenously. Recently, osteonecrosis of the jaw (ONJ) caused by chemotherapeutic not belonging to BPs drug class has been reported. For this reason, it has been proposed recently to rename BRONJ in antiresorptive agents related osteonecrosis of the jaw (ARONJ), to include a wider spectrum of drugs that may cause osteonecrosis of the jaw. The most debated topic about ARONJ/BRONJ is therapy. The most adequate procedure is far from being standardized and prevention seems to play a pivotal role. In our study, we considered 72 patients with BRONJ with nonsurgical therapy, surgical therapy, and surgical therapy with platelet rich plasma (PRP) gel to evaluate its therapeutic effect in promoting ONJ wounds healing. Good results showed by PRP in improving wound healing give away to case-control randomized studies that could give definitive evidence of its effectiveness.
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Affiliation(s)
- F Longo
- Division of Maxillofacial & ENT Surgery, Department of Melanoma, Sarcoma and Head and Neck Surgery, Istituto Nazionale Tumori-Fondazione G. Pascale-IRCCS, Via Aniello Falcone 186, 80127 Naples, Italy
| | - A Guida
- Postgraduate School in Oral Surgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - C Aversa
- Division of Maxillofacial & ENT Surgery, Department of Melanoma, Sarcoma and Head and Neck Surgery, Istituto Nazionale Tumori-Fondazione G. Pascale-IRCCS, Via Aniello Falcone 186, 80127 Naples, Italy
| | - E Pavone
- Division of Maxillofacial & ENT Surgery, Department of Melanoma, Sarcoma and Head and Neck Surgery, Istituto Nazionale Tumori-Fondazione G. Pascale-IRCCS, Via Aniello Falcone 186, 80127 Naples, Italy
| | - G Di Costanzo
- Division of Transfusion Medicine, Department of Haematology, Istituto Nazionale Tumori-Fondazione G. Pascale-IRCCS, Via Semmola 1, 80131 Naples, Italy
| | - L Ramaglia
- Postgraduate School in Oral Surgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - F Ionna
- Division of Maxillofacial & ENT Surgery, Department of Melanoma, Sarcoma and Head and Neck Surgery, Istituto Nazionale Tumori-Fondazione G. Pascale-IRCCS, Via Aniello Falcone 186, 80127 Naples, Italy
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