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Moreno-Rabié C, Fontenele RC, Oliveira-Santos N, Nogueira-Reis F, Van den Wyngaert T, Jacobs R. Key insights into antiresorptive drug use and osteonecrosis in osteoporotic patients undergoing tooth extractions: A clinical and CBCT assessment. Osteoporos Int 2024; 35:1431-1440. [PMID: 38767743 PMCID: PMC11282135 DOI: 10.1007/s00198-024-07108-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/25/2024] [Indexed: 05/22/2024]
Abstract
This study investigates the effects of antiresorptive drugs and risk factors for medication-related osteonecrosis of the jaws in osteoporotic patients undergoing tooth extraction. Among the findings, antiresorptive-treated patients had thicker lamina dura and longer healing times. Additionally, corticosteroid intake and multi-rooted teeth carried a higher osteonecrosis risk. Bone sequestrum indicated osteonecrosis. PURPOSE To describe the effects of antiresorptive drugs (ARD) in the maxilla and mandible and risk factors for medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients undergoing tooth extractions using clinical data and cone beam computed tomography (CBCT). METHODS This retrospective cohort study collected clinical and CBCT data from 176 patients. The study group (n = 78; 224 extractions) received ARD treatment, underwent tooth extraction, and had a pre-operative CBCT. Additionally, age-, sex-, and tooth-matched controls were selected (n = 98; 227 extractions). Radiographic examinations were performed independently by three calibrated examiners. Statistical analysis included Chi-square, Fisher's exact, Mann-Whitney U, and t-tests to contrast clinical and radiographic data between study and control, MRONJ + and MRONJ - , and bisphosphonate and denosumab patients/sites. Significance was set at p ≤ 0.05. RESULTS From the study group, 4 patients (5%) and 5 sites (2%) developed MRONJ after tooth extraction. ARD-treated patients exhibited significantly more thickening of the lamina dura and a longer average mucosal healing time (4.4 weeks) than controls (2.6 weeks). In the study group, MRONJ risk significantly increased with corticosteroid intake and in multi-rooted teeth. No significant differences between bisphosphonates and denosumab use were seen in the tomographic features (p > 0.05). Lastly, bone sequestrum was exclusively observed in osteoporotic patients, who exhibited post-operative exposed bone or histological evidence of osteonecrosis. CONCLUSION Osteoporotic patients under ARD may exhibit thickening of the lamina dura and prolonged post-operative healing. Among these patients, multi-rooted teeth are at higher risk for MRONJ than single-rooted teeth. Sequester formation is a radiographic indicator of osteonecrosis.
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Affiliation(s)
- Catalina Moreno-Rabié
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Rocharles Cavalcante Fontenele
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Nicolly Oliveira-Santos
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Fernanda Nogueira-Reis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Moreno-Rabié C, Gaêta-Araujo H, Ferreira-Leite A, Coucke W, Gielen E, Van den Wyngaert T, Jacobs R. Local radiographic risk factors for MRONJ in osteoporotic patients undergoing tooth extraction. Oral Dis 2024; 30:1632-1642. [PMID: 36620873 DOI: 10.1111/odi.14496] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To identify local radiographic risk factors for Medication-Related Osteonecrosis of the Jaws (MRONJ) in osteoporotic patients treated with antiresorptive drugs (ARD) and undergoing tooth extraction. MATERIAL AND METHODS Patients were included in this retrospective, longitudinal, case-control study, if having at least one administration of ARD, underwent tooth extraction(s), and had pre- and post-operative panoramic radiographs. Additionally, a matched control group was selected. Three calibrated, blinded, and independent observers assessed each tooth extraction site. Statistical analysis compared control against study group, and within the latter, sites MRONJ+ and MRONJ-. RESULTS In total, 120 patients (99 females/21 males) with 354 tooth extractions were included, from which nine patients (7.5%) and eleven tooth extraction sites (3.1%) developed MRONJ. When comparing control with study group, the latter showed significantly more thickened lamina dura, persistence of the alveolar socket, heterogeneous bone patterns, and sequestrum formation. In the study group, MRONJ developed significantly more in males (19%, p = 0.049), smokers (25%, p = 0.008), in the mandible (82%, p = 0.027), when identifying a radiolucent or sclerotic trabecular pattern (p = 0.004) or when extracting teeth with furcation involvement (p < 0.001), root remnants (p = 0.017), or unrestored caries lesions (p = 0.005). CONCLUSIONS Tooth extraction sites showing radiographic signs of chronic dental infection are prone to MRONJ.
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Affiliation(s)
- Catalina Moreno-Rabié
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hugo Gaêta-Araujo
- Department of Stomatology, Public Oral Health and Forensic Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - André Ferreira-Leite
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Brasilia, Brazil
| | - Wim Coucke
- Certified Freelance Statistician, Heverlee, Belgium
| | - Evelien Gielen
- Department of Geriatrics, Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
- Geriatrics and Gerontology, Department of Public Health and Primary Care, Leuven, Belgium
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Baseri Saadi S, Moreno-Rabié C, van den Wyngaert T, Jacobs R. Convolutional neural network for automated classification of osteonecrosis and related mandibular trabecular patterns. Bone Rep 2022; 17:101632. [DOI: 10.1016/j.bonr.2022.101632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
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Radiographic predictors for MRONJ in oncologic patients undergoing tooth extraction. Sci Rep 2022; 12:11280. [PMID: 35789184 PMCID: PMC9252989 DOI: 10.1038/s41598-022-15254-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/21/2022] [Indexed: 11/09/2022] Open
Abstract
Tooth extraction is a risk factor for the development of osteonecrosis of the jaw following treatment with antiresorptive drugs (ARDs), but not all extraction sites develop this pathology. Therefore, we aimed to identify local radiographic predictors of Medication-Related Osteonecrosis of the Jaw (MRONJ) in panoramic images of oncologic patients undergoing tooth extraction. Based on a retrospective longitudinal cohort study design, patients were included if undergoing one or more tooth extraction, with at least one administration of ARDs, and presence of pre- and post-operative panoramic radiographs. After data collection, blinded and independent observations were performed. Eleven distinct imaging-related parameters were assessed preoperatively and five postoperatively, at each extraction site. A case-control and subgroup analysis assessing MRONJ development was performed. Significance level is set to 0.05 (5%). A total of 77 oncologic patients were selected, undergoing 218 tooth extractions, from which 63 teeth (29%) in 39 patients (51%) developed MRONJ. Results showed that patients developed significantly more MRONJ with longer ARD treatment (p = 0.057), teeth with absent and incomplete endodontic fillings with caries, widened periodontal ligament space and/or periapical lesions (p = 0.005), and sclerotic and heterogenous bone patterns (p = 0.005). In conclusion, tooth extraction sites presenting with infections and bone sclerosis are at higher risk to develop MRONJ.
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Lorusso L, Pieruzzi L, Gabriele M, Nisi M, Viola D, Molinaro E, Bottici V, Elisei R, Agate L. Osteonecrosis of the jaw: a rare but possible side effect in thyroid cancer patients treated with tyrosine-kinase inhibitors and bisphosphonates. J Endocrinol Invest 2021; 44:2557-2566. [PMID: 34291429 PMCID: PMC8572199 DOI: 10.1007/s40618-021-01634-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/07/2021] [Indexed: 11/01/2022]
Abstract
Osteonecrosis of the jaw (ONJ) is a rare but very serious disease that can affect both jaws. It is defined as exposed bone in the maxillofacial region that does not heal within 8 weeks after a health care provider identification. ONJ can occur spontaneously or can be due to drugs like bisphosphonates (BPS) and anti-RANK agents, in patients with no history of external radiation therapy in the craniofacial region. Although in phase 3 trials of tyrosine kinase inhibitors (TKIs) used in thyroid cancer (TC) the ONJ was not reported among the most common side effects, several papers reported the association between ONJ and TKIs, both when they are used alone and in combination with a bisphosphonate. The appearance of an ONJ in a patient with metastatic radio-iodine refractory differentiated TC, treated with zoledronic acid and sorafenib, has put us in front of an important clinical challenge: when a ONJ occurred during TKIs treatment, it really worsens the patients' quality of life. We should consider that in the case of ONJ a TKI discontinuation becomes necessary, and this could lead to a progression of neoplastic disease. The most important aim of this review is to aware the endocrinologists/oncologists dealing with TC to pay attention to this possible side effect of BPS and TKIs, especially when they are used in association. To significantly reduced the risk of ONJ, both preventive measures before initiating not only antiresorptive therapy but also antiangiogenic agents, and regular dental examinations during the treatment should always be proposed.
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Affiliation(s)
- L. Lorusso
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - L. Pieruzzi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - M. Gabriele
- Department of Surgery, Section of Oral Surgery, University of Pisa, Pisa, Italy
| | - M. Nisi
- Department of Surgery, Section of Oral Surgery, University of Pisa, Pisa, Italy
| | - D. Viola
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - E. Molinaro
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - V. Bottici
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - R. Elisei
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - L. Agate
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
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Wongratwanich P, Shimabukuro K, Konishi M, Nagasaki T, Ohtsuka M, Suei Y, Nakamoto T, Verdonschot RG, Kanesaki T, Sutthiprapaporn P, Kakimoto N. Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review. Dentomaxillofac Radiol 2021; 50:20200417. [PMID: 33411572 DOI: 10.1259/dmfr.20200417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with medication-related osteonecrosis of the jaw (MRONJ) often visit their dentists at advanced stages and subsequently require treatments that greatly affect quality of life. Currently, no clear diagnostic criteria exist to assess MRONJ, and the definitive diagnosis solely relies on clinical bone exposure. This ambiguity leads to a diagnostic delay, complications, and unnecessary burden. This article aims to identify imaging modalities' usage and findings of MRONJ to provide possible approaches for early detection. METHODS Literature searches were conducted using PubMed, Web of Science, Scopus, and Cochrane Library to review all diagnostic imaging modalities for MRONJ. RESULTS Panoramic radiography offers a fundamental understanding of the lesions. Imaging findings were comparable between non-exposed and exposed MRONJ, showing osteolysis, osteosclerosis, and thickened lamina dura. Mandibular cortex index Class II could be a potential early MRONJ indicator. While three-dimensional modalities, CT and CBCT, were able to show more features unique to MRONJ such as a solid type periosteal reaction, buccal predominance of cortical perforation, and bone-within-bone appearance. MRI signal intensities of vital bones are hypointense on T1WI and hyperintense on T2WI and STIR when necrotic bone shows hypointensity on all T1WI, T2WI, and STIR. Functional imaging is the most sensitive method but is usually performed in metastasis detection rather than being a diagnostic tool for early MRONJ. CONCLUSION Currently, MRONJ-specific imaging features cannot be firmly established. However, the current data are valuable as it may lead to a more efficient diagnostic procedure along with a more suitable selection of imaging modalities.
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Affiliation(s)
- Pongsapak Wongratwanich
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Kiichi Shimabukuro
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masaru Konishi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Toshikazu Nagasaki
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masahiko Ohtsuka
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Yoshikazu Suei
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Takashi Nakamoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Rinus G Verdonschot
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Tomohiko Kanesaki
- Department of Oral and Maxillofacial Surgery, Saiseikai Senri Hospital, 1 Chome-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan
| | - Pipop Sutthiprapaporn
- Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Amphur Muang, Khon Kaen 40002, Thailand
| | - Naoya Kakimoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
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Kim JE, Yoo S, Choi SC. Several issues regarding the diagnostic imaging of medication-related osteonecrosis of the jaw. Imaging Sci Dent 2020; 50:273-279. [PMID: 33409135 PMCID: PMC7758260 DOI: 10.5624/isd.2020.50.4.273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 11/23/2022] Open
Abstract
This review presents an overview of some diagnostic imaging-related issues regarding medication-related osteonecrosis of the jaws (MRONJ), including imaging signs that can predict MRONJ in patients taking antiresorptive drugs, the early imaging features of MRONJ, the relationship between the presence or absence of bone exposure and imaging features, and differences in imaging features by stage, between advanced MRONJ and conventional osteomyelitis, between oncologic and osteoporotic patients with MRONJ, and depending on the type of medication, method of administration, and duration of medication. The early diagnosis of MRONJ can be made by the presence of subtle imaging changes such as thickening of the lamina dura or cortical bone, not by the presence of bone exposure. Most of the imaging features are relatively non-specific, and each patient's clinical findings and history should be referenced. Oral and maxillofacial radiologists and dentists should closely monitor plain radiographs of patients taking antiresorptive/antiangiogenic drugs.
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Affiliation(s)
- Jo-Eun Kim
- Department of Oral and Maxillofacial Radiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Sumin Yoo
- School of Dental Hygiene, Kyungdong University Medical Campus, Wonju, Korea
| | - Soon-Chul Choi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Seoul National University, Seoul, Korea
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Otto S, Pautke C, Arens D, Poxleitner P, Eberli U, Nehrbass D, Zeiter S, Stoddart MJ. A Drug Holiday Reduces the Frequency and Severity of Medication-Related Osteonecrosis of the Jaw in a Minipig Model. J Bone Miner Res 2020; 35:2179-2192. [PMID: 32568416 PMCID: PMC7689727 DOI: 10.1002/jbmr.4119] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
Treatment of medication-related osteonecrosis of the jaw (MRONJ) is challenging and no clear consensus has been achieved. This study investigated preventive measures recommended for tooth extractions under antiresorptive (AR) treatment and the role of discontinuation of AR therapy to avoid the onset of MRONJ in a minipig model. Thirty-six Göttingen minipigs were divided into four groups. Group 1 (negative control): tooth extractions but no zoledronate (ZOL). Group 2 (positive control): weekly ZOL infusions for 12 weeks followed by tooth extractions without wound management followed by 8 weeks of ZOL treatment. Group 3: weekly ZOL infusions for 12 weeks followed by tooth extractions; surgical wound management (resection of sharp bone edges, mucoperiosteal coverage); and continuation of ZOL infusions for 8 weeks plus antibiotic treatment. Group 4: 12 weeks of ZOL infusions followed by a drug holiday for 6 weeks. Tooth extractions with preventive wound management followed by antibiotic treatment for 8 weeks but no ZOL infusions. Jawbones were subjected to macroscopic, radiological (CT and micro-CT) and histopathological investigations. No clinical cases of MRONJ were observed in the negative group, in the positive control all animals developed MRONJ. Group 3 developed MRONJ in 83% of cases. With a drug holiday, 40% developed MRONJ in areas of tooth extraction. This is the first large animal model that reduces the occurrence of MRONJ following tooth extraction by the implementation of a drug holiday combined with antibiotic prophylaxis and smoothening of sharp bony edges. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research..
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany
| | | | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Freiburg, Germany
| | | | | | | | - Martin J Stoddart
- AO Research Institute Davos, Davos, Switzerland.,Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Freiburg, Germany
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Moreno-Rabié C, Gaêta-Araujo H, Oliveira-Santos C, Politis C, Jacobs R. Early imaging signs of the use of antiresorptive medication and MRONJ: a systematic review. Clin Oral Investig 2020; 24:2973-2989. [PMID: 32627123 DOI: 10.1007/s00784-020-03423-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The main aim is to identify, by means of different imaging modalities, the early bone changes in patients "at risk" and in stage 0 MRONJ. MATERIALS AND METHODS A search of the literature was performed on PubMed, Embase, Web of Science, and Cochrane Library databases, until June 9, 2020. No language or year restrictions were applied. Screening of the articles, data collection, and qualitative analysis was done. The Newcastle-Ottawa Scale (NOS) was used for observational studies, and the Systematic Review Centre for Laboratory Animal Experimentation's (SYRCLE) risk of bias tool for the animal studies. RESULTS A total of 1188 articles were found, from which 47 were considered eligible, whereas 42 were suitable for the qualitative analysis. They correspond to 39 human studies and 8 animal studies. Radiographic findings such as bone sclerosis, osteolytic areas, thickening of lamina dura, persisting alveolar socket, periapical radiolucency, thicker mandibular cortex, widening of the periodontal ligament space, periodontal bone loss, and enhancement of the mandibular canal were identified as early bone changes due to antiresorptive therapy. All those findings were also reported later in Stage 0 patients. CONCLUSION The main limitations of these results are the lack of prospective data and comparisons groups; therefore, careful interpretation should be made. It is a fact that radiographic findings are present in antiresorptive-treated patients, but the precise timepoint of occurrence, their relation to the posology, and potential risk to develop MRONJ are not clear. CLINICAL RELEVANCE The importance of a baseline radiographic diagnosis for antiresorptive-treated patients.
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Affiliation(s)
- Catalina Moreno-Rabié
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium.
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Hugo Gaêta-Araujo
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, Sao Paulo, Brazil
| | - Christiano Oliveira-Santos
- Department of Stomatology, Public Oral Health, Forensic Dentistry, Division of Oral Radiology, School of Dentistry of Ribeirao Preto, University of Sao Paulo, Sao Paulo, Brazil
| | - Constantinus Politis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Park JY, Heo HA, Park S, Pyo SW. Enhancement of peri-implant bone formation via parathyroid hormone administration in a rat model at risk for medication-related osteonecrosis of the jaw. J Periodontal Implant Sci 2020; 50:121-131. [PMID: 32395390 PMCID: PMC7192826 DOI: 10.5051/jpis.2020.50.2.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Dental implant-associated medication-related osteonecrosis of the jaw has been frequently reported in patients administered bisphosphonates (BPs) to prevent osteoporosis. The aim of this study was to investigate the effect of intermittent administration of parathyroid hormone (PTH) on peri-implant bone in the maxillae of ovariectomized rats systemically administered BPs. Methods Thirty 8-week-old female Sprague-Dawley rats were randomly divided into 3 groups. The OVX-ZP group included ovariectomized rats administered 60 µg/kg of zoledronate once a week for 6 weeks and 30 µg/kg PTH after implant installation. The OVX-Z group included ovariectomized rats administered 60 µg/kg of zoledronate once a week for 6 weeks and saline after implant installation, and the control group included rats that underwent a sham operation and were then administered saline. Rats were sacrificed 4 weeks after implant placement for histomorphometric and micro-computed tomography (CT) analyses. Results The average bone area percentage was greater in the OVX-ZP group than in the OVX-Z group (53.4%±4.0% vs. 28.9%±9.5%, P=0.01). The bone-to-implant contact ratio was 50.8%±1.4% in the OVX-ZP group and 16.9%±2.4% in the OVX-Z group (P=0.012). The average bone volume ratio as shown on micro-CT was 31.3%±19.8% in the OVX-ZP group and 19.4%±9.3% in the OVX-Z group (P=0.045). The OVX-ZP and OVX-Z groups displayed similar trabecular thickness (0.06±0.004 mm vs. 0.06±0.002 mm) (P>0.05) and trabecular separation (0.21±0.02 mm vs. 0.29±0.13 mm) (P>0.05). However, the number of trabeculae in the OVX-ZP group was significantly higher than that in the OVX-Z group (4.3±1.33/mm3 vs. 2.2±0.19/mm3) (P=0.024). Conclusions The present findings indicate that intermittently-administered PTH can promote peri-implant bone formation and suggest that PTH administration may aid in effective treatment for medication-related osteonecrosis of the jaw after dental implantation.
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Affiliation(s)
- Ji Young Park
- Department of Dentistry, Graduate School, The Catholic University of Korea, Seoul, Korea
| | - Hyun A Heo
- Department of Dentistry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suhyun Park
- Department of Dentistry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Woon Pyo
- Department of Dentistry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Fusco V, Santini D, Campisi G, Bertoldo F, Lanzetta G, Ibrahim T, Bertetto O, Numico G, Addeo A, Berruti A, Bettini G, Saia G, Bedogni A. Comment on Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline Summary. JCO Oncol Pract 2020; 16:142-145. [PMID: 32048935 DOI: 10.1200/jop.19.00645] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Affiliation(s)
- Vittorio Fusco
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Daniele Santini
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Giuseppina Campisi
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Francesco Bertoldo
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Gaetano Lanzetta
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Toni Ibrahim
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Oscar Bertetto
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Gianmauro Numico
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Alfredo Addeo
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Alfredo Berruti
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Giordana Bettini
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Giorgia Saia
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
| | - Alberto Bedogni
- Vittorio Fusco, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Daniele Santini, MD, Oncology Department, Campus Biomedico University, Rome, Italy; Giuseppina Campisi, DDS, MS, Sector of Oral Medicine, Dip DICHIRONS, Università degli Studi di Palermo, Palermo, Italy; Francesco Bertoldo, MD, Medicine Department, Università di Verona, Verona, Italy; Gaetano Lanzetta, MD, Oncology Unit, INI, Grottaferrata, Italy; Toni Ibrahim, MSc, MD, PhD, Osteoncology and Rare Tumors Center. Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; Oscar Bertetto, MD, Rete Oncologica Department, Torino, Italy; Gianmauro Numico, MD, Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; Alfredo Addeo, MD, Oncology Service, Hopiteaux Universitaires de Geneve, Geneve, Switzerland; Alfredo Berruti, MD, Medical Oncology Unit, University of Brescia, ASST-Spedali Civili, Brescia, Italy; and Giordana Bettini, MD; Giorgia Saia, MD; and Alberto, Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padua, Padua, Italy
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Imaging and histomorphometric evaluation of mandible and tibia of rats treated with bisphosphonates. Oral Maxillofac Surg 2019; 23:473-479. [PMID: 31686251 DOI: 10.1007/s10006-019-00807-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/11/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To evaluate the mandible and tibia of rats treated with bisphosphonates (BPs) by imaging and histomorphometric analysis. STUDY DESIGN Thirty-four rat specimens (Rattus norvegicus, Wistar strain) were distributed into 3 groups: (1) 12 rats treated with zoledronic acid; (2) 12 rats treated with clodronate; and (3) the control group, containing 10 rats that received saline. All bones were exposed to cone beam computed tomography (CBCT). The images were analyzed to determine bone density (BD), using the software OsiriX 7.0. Histological slides were prepared from the specimens and the proportion of bone volume (BV) was quantified using the software Adobe Photoshop CC. RESULTS There was no statistically significant difference in BD either between the drug groups or between mandible and tibia. BV between BPs and control group did not show a significant difference. However, comparing the two bones, the mandibles in the control group displayed higher BV than did the tibiae in the same group. CONCLUSION According to our results, we conclude that (1) BD was not altered by bone type or by type of BP administered, and (2) treatment with zoledronic acid or clodronate did not affect BV in the mandible or tibia of test groups.
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Şahin O, Odabaşı O, Demiralp KÖ, Kurşun-Çakmak EŞ, Aliyev T. Comparison of findings of radiographic and fractal dimension analyses on panoramic radiographs of patients with early-stage and advanced-stage medication-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:78-86. [DOI: 10.1016/j.oooo.2019.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 01/09/2023]
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Nowicki B, Nehrbass D, Arens D, Stadelmann VA, Zeiter S, Otto S, Kircher P, Stoddart MJ. Medication-related osteonecrosis of the jaw in a minipig model: Parameters for developing a macroscopic, radiological, and microscopic grading scheme. J Craniomaxillofac Surg 2019; 47:1162-1169. [PMID: 30952472 DOI: 10.1016/j.jcms.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/13/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES To devise a macroscopic, radiological, and histological scale for assessing pathological changes associated with medication-related osteonecrosis of the jaw in a minipig model. MATERIALS AND METHODS Medication-related osteonecrosis of the jaw was induced in Göttingen minipigs by weekly intravenous administration of bisphosphonate (zoledronic acid) combined with a tooth extraction procedure. Controls either did not receive zoledronic acid or did not undergo tooth extraction. After 20 weeks, minipigs were euthanized and underwent computed tomography and micro-computed tomography scanning. The mandible underwent additional histological examination. RESULTS The most consistent macroscopic findings in animals that had developed bisphosphonate-related osteonecrosis of the jaw (BRONJ) were necrotic, denuded bone, and formation of fistula and pus. Under radiological examination, impaired extraction socket healing, decrease in attenuation of bone beneath the extraction site, and periosteal reaction were observed. Under histological examination, demineralization of the extracellular bone matrix, denuding of bone, and osteonecrosis were recorded. CONCLUSION These parameters were used to develop a scoring system for grading BRONJ.
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Affiliation(s)
- B Nowicki
- AO Research Institute Davos, Davos Platz, Switzerland
| | - D Nehrbass
- AO Research Institute Davos, Davos Platz, Switzerland
| | - D Arens
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | - S Zeiter
- AO Research Institute Davos, Davos Platz, Switzerland
| | - S Otto
- Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany
| | - P Kircher
- Department of Veterinary Radiology, University of Zurich, Zurich, Switzerland
| | - M J Stoddart
- AO Research Institute Davos, Davos Platz, Switzerland; Medical Faculty, Albert Ludwigs University of Freiburg, Freiburg, Germany.
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Matsuo A, Hamada H, Takahashi H, Chikazu D. Long-term structural changes and outcomes of implants in particulate cellular bone and marrow reconstructed jawbone. Clin Implant Dent Relat Res 2019; 21:360-368. [PMID: 30785240 DOI: 10.1111/cid.12723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Association between long-term structural changes of grafted bone and outcomes of the implants is not clear. PURPOSE Morphometrical measurements and implant success were analyzed in subjects of particulate cellular bone and marrow (PCBM) reconstruction of the jawbone. MATERIALS AND METHODS Subjects were 30 implants in 13 patients from a series of 24 PCBM reconstruction cases. The cortical bone thickness and cancellous computed tomography (CT) radiodensity values were retrospectively analyzed from the CT data of 27 subjects. The cumulative success rate of the implants in the PCBM reconstructed cases (pure graft) was compared with that of 127 implants of 56 native bone cases and 42 implants of 28 bone augmentation (partial graft) cases. RESULTS In areas of PCBM reconstruction, cancellous CT radiodensity values were significantly high immediately after the surgery, and subsequently the values became stable. Cortical thickness was significantly increased, but did not reach that of native bone. Implant success rates were statistically not different (P = 0.783) between the native bone (91.3%), the partially grafted bone (95.2%), and the PCBM reconstructed bone (93.3%). CONCLUSION Implants in pure grafted bone are mainly supported by cancellous bone, because cortical thickness remained thin for a long period of time.
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Affiliation(s)
- Akira Matsuo
- Department of Oral and Maxillofacial Surgery, Ibaraki Medical Center, Tokyo Medical University, Ibaraki, Japan
| | - Hayato Hamada
- Faculty of Medicine, Department of Oral and Maxillofacial Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hidetoshi Takahashi
- Faculty of Medicine, Department of Oral and Maxillofacial Surgery, Tokyo Medical University, Tokyo, Japan
| | - Daichi Chikazu
- Faculty of Medicine, Department of Oral and Maxillofacial Surgery, Tokyo Medical University, Tokyo, Japan
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Sánchez-López JD, Cariati P, Cambil-Martin J, Villegas-Calvo M, Moreno-Martin ML. Use of bone scintigraphy in the early diagnosis of bisphosphonate related osteonecrosis of the jaw. Case report and review of the literature. J Clin Exp Dent 2018; 10:e1235-e1237. [PMID: 30697384 PMCID: PMC6343969 DOI: 10.4317/jced.55248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/15/2018] [Indexed: 01/27/2023] Open
Abstract
The main aim of the present report is to show the potential utility of bone scintigraphy for the diagnosis of jaw osteonecrosis. We report the history of a 62-year-old woman underwent breast cancer surgery in 2010. Moreover, patient received postoperative radiotherapy and chemotherapy. Intravenous bisphosphonates were also added to the treatment strategy to reduce the risk of bone metastasis. However, a hypermetabolic focus on left hemimandible was evidenced with a bone scintigraphy during follow up. After a careful study, the diagnosis of Bisphosphonate Related Ostneonecrosis of the Jaw (BRONJ) was carried out. This case highlights that bone scintigraphy may be extremely helpful for the early detection of BRONJ in high risk patient. Key words:Bone scintigraphy, mandibular osteonecrosis, bisphosphonates.
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Affiliation(s)
- José-Darío Sánchez-López
- Department of Oral an Maxillofacial Surgery. Universitary Hospital "Virgen de las Nieves". Granada (Spain)
| | - Paolo Cariati
- Department of Oral an Maxillofacial Surgery. Universitary Hospital "Virgen de las Nieves". Granada (Spain)
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Effect of bisphosphonate treatment on the jawbone: an exploratory study using periapical and panoramic radiographic evaluation. Oral Radiol 2018; 35:159-170. [DOI: 10.1007/s11282-018-0358-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/13/2018] [Indexed: 11/30/2022]
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Koo CH, Lee JH. Evaluation of mandibular cortical bone ratio on computed tomography images in patients taking bisphosphonates. Maxillofac Plast Reconstr Surg 2018; 40:17. [PMID: 30038904 PMCID: PMC6031557 DOI: 10.1186/s40902-018-0153-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/08/2018] [Indexed: 11/23/2022] Open
Abstract
Background Bisphosphonate (BP) has the ability to thicken the cortical bone. In addition, it has been reported that the cortical bone thickened by BP has relation to the medication-related osteonecrosis of the jaw (MRONJ). Therefore, the objective of this article is to analyze the ratio as well as thickness of cortical bone in the mandible using computed tomography (CT) and to evaluate it as the predictive factor of MRONJ. Methods The thickness of the cortical bone was measured on a paraxial view of the CT showing the mental foramen in 95 patients: 33 patients with MRONJ (3 males, 30 females), 30 patients taking BP without MRONJ (2 males, 28 females), and 32 controls (9 males, 28 females). Also, the ratios of the cortical bone to the total bone were obtained using the measured values. Based on these results, we compared the difference of mandibular cortical bone ratio between the three groups. Results The average cortical bone thickness was measured as 3.81 mm in patients with MRONJ, 3.39 mm in patients taking BP without MRONJ, and 3.23 mm in controls. There was only a significant difference between patients with MRONJ and controls (P < 0.05). On the other hand, the average mandibular cortical bone ratio was measured as 37.9% in patients with MRONJ, 27.9% in patients taking BP without MRONJ, and 23.3% in controls. There was a significant difference between all groups (P < 0.05). Conclusion The mandibular cortical bone ratio is large in order of patients with MRONJ, patients taking BP without MRONJ, and controls. This result suggests that the mandibular cortical bone ratio would be very useful to predict the development of MRONJ.
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Affiliation(s)
- Chul-Hong Koo
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, South Korea
| | - Jae-Hoon Lee
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, South Korea
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19
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Barngkgei I, Khattab R. Detecting the effect of bisphosphonates during osteoporosis treatment on jawbones using multidetector computed tomography: The
OSTEOSYR
project. ACTA ACUST UNITED AC 2018; 9:e12332. [DOI: 10.1111/jicd.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/19/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Imad Barngkgei
- Department of Oral MedicineFaculty of DentistrySyrian Private University Damascus Syria
- Department of Oral MedicineFaculty of DentistryDamascus University Damascus Syria
| | - Razan Khattab
- Department of PeriodontologyFaculty of DentistryDamascus University Damascus Syria
- Department of PeriodontologyFaculty of DentistryAlsham Private University Damascus Syria
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20
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Demiralp KÖ, Kurşun-Çakmak EŞ, Bayrak S, Akbulut N, Atakan C, Orhan K. Trabecular structure designation using fractal analysis technique on panoramic radiographs of patients with bisphosphonate intake: a preliminary study. Oral Radiol 2018; 35:23-28. [PMID: 30484181 DOI: 10.1007/s11282-018-0321-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/29/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study was performed to evaluate the trabecular pattern of patients with cancer taking bisphosphonates on panoramic images using fractal dimension (FD) analysis by comparison with healthy subjects and to assess whether any difference exists between regions. METHODS FD analysis was conducted using ImageJ 1.3 software (National Institutes of Health, Bethesda, MD, USA) with the box-counting method on panoramic radiographs of 33 patients taking bisphosphonates (13 males and 20 females) and 33 healthy sex- and age-matched individuals. RESULTS FD values were higher (1.39 ± 0.14) in the study group than control group (1.38 ± 0.07) (p ≤ 0.05). No difference was detected in the FD values among the tested regions. The mean FD values in the control and study groups were as follows: region 1, 1.49 and 1.41 (p = 0.54); region 2, 1.36 and 1.37 (p = 0.84); region 3, 1.35 and 1.42 (p = 0.11); and region 4, 1.39 and 1.39 (p = 0.90), respectively. Female patients showed significantly lower values above the mandibular canal on the distal side of the second premolar and anterior to the mental foramen than did male patients (p ≤ 0.05). Age was unrelated to the FD in the study group (p ≥ 0.05). CONCLUSIONS The FD values of the patients with cancer taking bisphosphonates were higher than those of the controls. FD analysis showed the potential for examining bone structure in panoramic radiographs. Studies with a larger sample size are necessary to confirm these results.
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Affiliation(s)
- Kemal Özgür Demiralp
- Türkiye Public Hospitals Agency, Ministry of Health, Cankaya, 06490, Ankara, Turkey
| | | | - Seval Bayrak
- Dentomaxillofacial Radiology Department, Dentistry Faculty, Abant İzzet Baysal University, Gölköy Yerleşkesi, Gölköy Kampüsü, Gölköy, 14280, Bolu Merkez, Bolu, Turkey.
| | - Nihat Akbulut
- Dentomaxillofacial Surgery Department, Dentistry Faculty, Gaziosmanpasa University, Tasliciftlik yerleskesi, Merkez, 60250, Tokat Merkez, Tokat, Turkey
| | - Cemal Atakan
- Statistics Department, Faculty of Sciences, Ankara University, Dogol Cad., Besevler, 06100, Yenimahalle, Ankara, Turkey
| | - Kaan Orhan
- Dentomaxillofacial Radiology Department, Faculty of Dentistry, Ankara University, Besevler, 06500, Ankara, Turkey
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21
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Gönen ZB, Yillmaz Asan C, Zararsiz G, Kiliç E, Alkan A. Osseous changes in patients with medication-related osteonecrosis of the jaws. Dentomaxillofac Radiol 2017; 47:20170172. [PMID: 28871814 DOI: 10.1259/dmfr.20170172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive agents. The aim of this study was to investigate the osseous changes in patients with MRONJ. METHODS Cone beam CT (CBCT) images of 25 patients with MRONJ and controls were retrospectively evaluated. Buccal, lingual, apical cortical bone thicknesses; buccal, lingual, apical intracortical and cancellous bone density; diameter of mental foramen and incisive canal, and width of mental foramen were measured. RESULTS Buccal and apical cortical bone thicknesses were increased; however intracortical radiodensity values decreased in the Study Group when compared with the Control Group (p = 0.007, p = 0.001). Narrowing of incisive canal was observed in patients with MRONJ (p = 0.000). CONCLUSIONS Clinician should have awareness about narrowing of incisive canal, apical and buccal cortical bone thickening, decreasing in cancellous bone radiodensity, and the lingual cortex destruction in patients with MRONJ.
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Affiliation(s)
- Zeynep Burcin Gönen
- 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry and Genome - Stem Cell Center, Erciyes University, Kayseri, Turkey
| | - Canay Yillmaz Asan
- 2 Department of Oral and Maxillofacial Surgery, Ministry of Dental Health Hospital, Kayseri, Turkey
| | - Gökmen Zararsiz
- 3 Department of Biostatistics, Faculty of Medicine, Erciyes University and Turcosa Analytics Solutions Ltd. Co, Erciyes Teknopark, Kayseri, Turkey
| | - Erdem Kiliç
- 4 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem University, Istanbul, Turkey
| | - Alper Alkan
- 4 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem University, Istanbul, Turkey
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22
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Eleutherakis-Papaiakovou E, Bamias A. Antiresorptive treatment-associated ONJ. Eur J Cancer Care (Engl) 2017; 26. [PMID: 29063702 DOI: 10.1111/ecc.12787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 01/22/2023]
Abstract
Osteonecrosis of the jaw (ONJ) is a severe complication of therapy with antiresorptive agents (e.g. bisphosphonates and denosumab), which are used to manage bone metastases from cancer, to reduce the incidence of skeletal-related events. Available data indicate that 0-27, 5% of patients exposed to antiresorptive agents may develop ONJ, depending on the number of infusions and the duration of therapy. Besides antiresorptive therapy, a number of risk factors for osteonecrosis have been identified. Oral surgical procedures, tooth extractions and infection to the jawbones are considered the main risk factors for developing ONJ, when receiving antiresorptive therapy. However, a growing number of patients develop ONJ without apparent risk factors, raising concern for other predisposing factors. Jaw bone necrosis may be irreversible, resulting in a chronic disease with negative impact on the quality of patients' lives. The role of risk reduction strategies like meticulous dental screening and optimal oral hygiene is fundamental for preventing development of ONJ. ONJ is usually treated conservatively to relieve the symptoms and manage jaw bone necrosis. In certain cases, surgical intervention is required. Future research should emphasize individual predisposition to ONJ, more effective preventive measures and more efficient therapeutic procedures.
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Affiliation(s)
- Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
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Vilarinho JLP, Ferrare N, Moreira AMR, Moura HF, Acevedo AC, Chaves SB, Melo NS, Leite AF, Macedo SB, de Souza MP, Guimarães ATB, Figueiredo PT. Early bony changes associated with bisphosphonate-related osteonecrosis of the jaws in rats: A longitudinal in vivo study. Arch Oral Biol 2017. [PMID: 28622548 DOI: 10.1016/j.archoralbio.2017.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate early bony changes in an animal model of Medication-Related Osteonecrosis of the Jaw (MRONJ) at the side of the local trauma and at the contralateral side, comparing with a control group. Bony changes were evaluated by Microcomputed Tomography (MicroCT) at three times points: at baseline (T0), after drug administration (T1) and after dental extraction (T2). DESIGN Two groups were compared: the experimental group in which zoledronic acid (ZA) was administered (17 rats) and the control group (13 rats). Dental extractions of the lower left first molars were performed in all animals. The left side was considered as the supposed affected area in the ZA group, and the right side was considered as the unaffected area. In these areas, the following structural microtomographic bone parameters were calculated: Bone Mineral Density (BMD), Trabecular Thickness (Tb.Th), and Bone Volume Proportion (BV/TV). The comparison of quantitative bone parameters among the different sides and experimental phases of both studied groups were performed by ANOVA-factorial. RESULTS None of the animals of the control group developed MRONJ. In the ZA group, 76% presented bone exposure. From T0 to T1, Tb.Th and BV/TV increased, and in T2, the mean values were higher in ZA group than in the control group. BMD increased throughout the different phases of both groups. CONCLUSIONS Structural bony changes occurred in the ZA group at both mandibular sides before the dental extraction (T1). Tb.Th and BV/TV should be further investigated as potential early bone markers of MRONJ.
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Affiliation(s)
- Josy Lorena Peres Vilarinho
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Nathália Ferrare
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Andreia Maria Rocha Moreira
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Helora Freitas Moura
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Ana Carolina Acevedo
- Oral Care Center for Inherited Diseases, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Sacha Braun Chaves
- Biology Institute University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Nilce Santos Melo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - André Ferreira Leite
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Sérgio Bruzadelli Macedo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Melissa Paoletti de Souza
- Biological Sciences Department, State University of West Paraná, Rua Universitária 2069, Cascavel, Zip Code: 85819-110, Paraná, Brazil.
| | - Ana Tereza Bittencourt Guimarães
- Biological Sciences Department, State University of West Paraná, Rua Universitária 2069, Cascavel, Zip Code: 85819-110, Paraná, Brazil.
| | - Paulo Tadeu Figueiredo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
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Taguchi A, Shiraki M, Morrison A, Khan AA. Antiresorptive agent-related osteonecrosis of the jaw in osteoporosis patients from Asian countries. Osteoporos Sarcopenia 2017; 3:64-74. [PMID: 30775507 PMCID: PMC6372774 DOI: 10.1016/j.afos.2017.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/05/2022] Open
Abstract
Bisphosphonate (BP)-associated osteonecrosis of the jaw (ONJ) was first reported in oncology patients in 2003 and subsequently in osteoporosis patients in 2004. Since oral surgical procedures, such as tooth extraction, are also considered one of the major risk factors for ONJ, there is confusion among physicians, dentists, and patients—particularly osteoporosis patients currently taking BPs—regarding the safety of remaining on therapy surrounding these procedures. Many papers about BP-related ONJ (BRONJ) have been published to date. In addition to BRONJ, recent studies have reported an association between ONJ and the antiresorptive therapy denosumab (Dmab; a RANKL-inhibitor). BRONJ and Dmab-related ONJ are together referred to as antiresorptive agent-related ONJ (ARONJ). The pathogenesis of ARONJ still remains unknown. It is forecasted that there will be an increased incidence of patients with osteoporotic fractures and an increased number of prescriptions for antiresorptive agents in Asia in the future. However, prescriptions for antiresorptives for osteoporosis may be restricted in the Asian population as the occurrence of ARONJ may be higher as compared with those in other countries. In this review, we focused on the following topics as it pertains to the Asian osteoporotic population: the oral condition specific for osteoporosis patients; definition, staging, prevalence and incidence of ARONJ; imaging modalities for ARONJ; specific risk factors for ARONJ; prevention strategies for ARONJ, and; cooperation between physicians and dentists in the prevention of ARONJ. Ideally, the Asian Federation of Osteoporosis Societies would cooperate with one another and find more population-specific evidence for the prevention of ARONJ.
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Affiliation(s)
- Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shiojiri, Japan
| | - Masataka Shiraki
- Research Institute and Practice for Involutional Diseases, Nagano, Japan
| | | | - Aliya A Khan
- Divisions of Endocrinology and Metabolism and Geriatrics, Department of Medicine, McMaster University, Hamilton, ON, Canada
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25
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Bagan L, Leopoldo-Rodado M, Poveda-Roda R, Murillo-Cortes J, Diaz-Fernández J, Bagan J. Grade of sclerosis in the contralateral mandibular area in osteonecrosis of the jaws. Int J Oral Maxillofac Surg 2017; 46:167-172. [DOI: 10.1016/j.ijom.2016.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 08/03/2016] [Accepted: 09/29/2016] [Indexed: 11/29/2022]
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26
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Martelli SJR, Damian MF, Gomes APN, Schinestsck AR, Silva AER, Vasconcelos ACU. Comparison of effects of zoledronic acid and clodronate on the bone structure: imaginological and histomorphometrical study in vivo. J Oral Pathol Med 2017; 46:632-636. [DOI: 10.1111/jop.12546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 01/21/2023]
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27
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Watanabe S, Nakajima K, Mizokami A, Yaegashi H, Noguchi N, Kawashiri S, Inokuchi M, Kinuya S. Bone scan index of the jaw: a new approach for evaluating early-stage anti-resorptive agents-related osteonecrosis. Ann Nucl Med 2016; 31:201-210. [DOI: 10.1007/s12149-016-1145-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/10/2016] [Indexed: 12/13/2022]
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Berg BI, Mueller AA, Augello M, Berg S, Jaquiéry C. Imaging in Patients with Bisphosphonate-Associated Osteonecrosis of the Jaws (MRONJ). Dent J (Basel) 2016; 4:E29. [PMID: 29563471 PMCID: PMC5806936 DOI: 10.3390/dj4030029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/11/2016] [Accepted: 08/17/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Bisphosphonate-associated osteonecrosis of the jaws (MRONJ/BP-ONJ/BRONJ) is a commonly seen disease. During recent decades, major advances in diagnostics have occurred. Once the clinical picture shows typical MRONJ features, imaging is necessary to determine the size of the lesion. Exposed bone is not always painful, therefore a thorough clinical examination and radiological imaging are essential when MRONJ is suspected. METHODS In this paper we will present the latest clinical update on the imaging options in regard to MRONJ: X-ray/Panoramic Radiograph, Cone Beam Computed Tomography (CBCT) and Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Nuclear Imaging, Fluorescence-Guided Bone Resection. CONCLUSION Which image modality is chosen depends not only on the surgeon's/practitioner's preference but also on the available imaging modalities. A three-dimensional imaging modality is desirable, and in severe cases necessary, for extended resections and planning of reconstruction.
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Affiliation(s)
- Britt-Isabelle Berg
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
- Division of Oral and Maxillofacial Radiology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Andreas A Mueller
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
| | - Marcello Augello
- Clinic of Cranio-Maxillofacial Surgery, Kantonsspital Aarau, 5001 Aarau, Switzerland.
| | - Scott Berg
- Private Practice, 25524 Itzehoe, Germany.
| | - Claude Jaquiéry
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
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29
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Imaging features of medicine-related osteonecrosis of the jaws: comparison between panoramic radiography and computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:e69-76. [DOI: 10.1016/j.oooo.2016.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/04/2016] [Accepted: 04/12/2016] [Indexed: 01/09/2023]
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30
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Taniguchi T, Ariji Y, Nozawa M, Naitoh M, Kuroiwa Y, Kurita K, Ariji E. Computed tomographic assessment of early changes of the mandible in bisphosphonate-treated patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:362-72. [PMID: 27544397 DOI: 10.1016/j.oooo.2016.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 06/04/2016] [Accepted: 06/08/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To compare the computed tomography (CT) features of mandibular cancellous and cortical bones between patients with bisphosphonate (BP) administration and those without and to assess the early changes of the mandible in BP-treated patients. STUDY DESIGN Twenty-four BP-treated patients suffering from medication-related osteonecrosis of the jaw (MRONJ) were enrolled in this study. For comparison, 20 patients suffering from osteomyelitis and 20 patients without pathology in the jaw were also enrolled, all of whom did not receive BP treatment. The CT values of the cancellous and cortical bone and the cortical bone widths were measured. RESULTS In the MRONJ and osteomyelitis groups, there were significant differences in the CT values of cancellous and cortical bones between the affected and unaffected areas. In patients with stage 0 MRONJ, a significant difference was noted in the cancellous bone CT values between these areas. The cancellous bone CT values at the affected and unaffected areas in the BP-treated group were significantly higher than in the control groups. In patients with stage 0 MRONJ, the cancellous bone CT values at the affected area were also significantly higher than in the healthy patients. The cortical bone widths in the unaffected areas in the BP-treated patients were significantly larger than in healthy patients. CONCLUSIONS The cancellous bone CT values were higher in the BP-treated group, including in patients with stage 0 MRONJ, and CT may provide useful quantitative information.
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Affiliation(s)
- Tohru Taniguchi
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
| | - Yoshiko Ariji
- Associate Professor, Department of Oral and Maxillofacial Radiology, Aichi-Gakuin University School of Dentistry, Nagoya, Japan.
| | - Michihito Nozawa
- Postgraduate Student, Department of Oral and Maxillofacial Radiology, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
| | - Munetaka Naitoh
- Associate Professor, Department of Oral and Maxillofacial Radiology, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
| | - Yuichiro Kuroiwa
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
| | - Kenichi Kurita
- Professor and Chairman, Department of Oral and Maxillofacial Surgery, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
| | - Eiichiro Ariji
- Professor and Chairman, Department of Oral and Maxillofacial Radiology, Aichi-Gakuin University School of Dentistry, Nagoya, Japan
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Koth VS, Figueiredo MA, Salum FG, Cherubini K. Bisphosphonate-related osteonecrosis of the jaw: from the sine qua non condition of bone exposure to a non-exposed BRONJ entity. Dentomaxillofac Radiol 2016; 45:20160049. [PMID: 27167455 DOI: 10.1259/dmfr.20160049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The present work aimed to review the literature focusing on the diagnostic criteria for bisphosphonate-related osteonecrosis of the jaw (BRONJ) and its implications regarding the management of the disease. Since the report of the first cases, BRONJ concepts, diagnostic criteria and guidelines have been changed. The presence of bone exposure in the oral cavity was at first a sine qua non condition for diagnosis. However, it seems that the great concern now is the possibility of occurrence of BRONJ without this feature. Some authors warn that the bone exposure criterion leads to late diagnosis and poor response to treatment. Meanwhile, some radiographic features, such as bone sclerosis, have been postulated as early signs of the disease. Criticisms have also been raised about the clinical staging system of BRONJ. While there is no consensus on the subject, common sense recommends treating symptomatic patients taking bisphosphonate as having BRONJ despite the absence of bone exposure; and asymptomatic patients must be kept under dental follow-up, since all of them are at risk for BRONJ.
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Affiliation(s)
- Valesca Sander Koth
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria Antonia Figueiredo
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda Gonçalves Salum
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Karen Cherubini
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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Pabst AM, Krüger M, Sagheb K, Ziebart T, Jacobs C, Blatt S, Goetze E, Walter C. The influence of geranylgeraniol on microvessel sprouting after bisphosphonate substitution in an in vitro 3D-angiogenesis assay. Clin Oral Investig 2016; 21:771-778. [PMID: 27170294 DOI: 10.1007/s00784-016-1842-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/24/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Recent studies focused on angiogenesis in the pathophysiology of bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) and identified geranylgeraniol (GGOH) as a feasible option for BP-ONJ therapy. This study investigated the influence of GGOH on microvessel sprouting after BP-incubation in vitro. MATERIALS AND METHODS Ten experimental set-ups were randomly designed in an in vitro 3D-angiogenesis assay. Two groups included HUVEC cell spheroids with and without (±) GGOH substitution as controls and eight groups pairwise contained either clodronate or the nitrogen-containing bisphosphonates (N-BP) ibandronate, pamidronate, and zoledronate ± GGOH. The size of the cell spheroids including the outbranching sprouts (SpS) as well as the density (SpD) and length of the sprouts (SpL) were analyzed by a grid system after 0, 24, 48, and 72 h. RESULTS For controls and NN-BP clodronate, no significant differences at any tested parameter and any point of measurement could be detected within the experimental set-ups ± GGOH (p each ≥0.05). For N-BP ibandronate, the experimental set-ups +GGOH showed a significantly increased SpS, SpD, and SpL after 48 and 72 h (p each ≤0.002) compared to the experimental set-ups -GGOH. For N-BPs pamidronate and zoledronate, the experimental set-ups + GGOH demonstrated a significantly increased SpS, SpD, and SpL after 24, 48, and 72 h (p each ≤0.001) compared to the experimental set-ups -GGOH. CONCLUSIONS The strong negative influence of N-BPs on microvessel sprouting could be significantly reversed by GGOH. CLINICAL RELEVANCE Since supportive therapeutic options for BP-ONJ are lacking, GGOH might be a promising substitute for BP-ONJ prevention and therapy.
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Affiliation(s)
- A M Pabst
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstr, 170, 56072, Koblenz, Germany. .,Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany.
| | - M Krüger
- Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - K Sagheb
- Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - T Ziebart
- Department of Oral and Maxillofacial Surgery, University Clinic, Georg-Voigt-Straße 3, 35039, Marburg, Germany
| | - C Jacobs
- Department of Orthodontics, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - S Blatt
- Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - E Goetze
- Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - C Walter
- Department of Oral and Maxillofacial Surgery, University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
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Evaluation and comparison of CT values in bisphosphonate-related osteonecrosis of the jaw. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2016. [DOI: 10.1016/j.ajoms.2015.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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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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Bagan JV, Cibrian RM, Lopez J, Leopoldo-Rodado M, Carbonell E, Bagán L, Utrilla J, Scully C. Sclerosis in bisphosphonate-related osteonecrosis of the jaws and its correlation with the clinical stages: study of 43 cases. Br J Oral Maxillofac Surg 2015; 53:257-62. [PMID: 25560326 DOI: 10.1016/j.bjoms.2014.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 12/07/2014] [Indexed: 12/20/2022]
Abstract
We analysed the degree of sclerosis in the different stages of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and studied the relation between the grade of sclerosis, the clinical symptoms, and the depth of lucency. We compared 43 patients with mandibular BRONJ with a control group of 40 cases with no bony lesions. The presence of sclerotic bone, cortical irregularities, radiolucency, fragmentation or sequestration, periostitis, and narrowing of the mandibular canal were studied from computed tomographic (CT) scans using the program ImageJ 1.47v (National Institute of Health, Bethesda, USA) to measure the radiolucency, width of the cortices, and degree of sclerosis. Patients with BRONJ had more severe sclerosis than controls (p<0.01). There was also a significant difference among the different stages of BRONJ, with the highest values found in stage III (p=0.02). The degree of sclerosis differed according to sex, type of bisphosphonate, and the clinical characteristics such as pain, or suppuration, but not significantly so (p>0.05). We conclude that the degree of sclerosis increases with the clinical stage of BRONJ, and is correlated with the depth of lucency.
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Affiliation(s)
- J V Bagan
- Oral Medicine, Valencia University, Spain; Department of Oral and Maxillofacial Surgery, University General Hospital, Valencia, Spain.
| | - R M Cibrian
- Department of Physiology, Valencia University, Spain
| | - J Lopez
- Department of Physiology, Valencia University, Spain
| | - M Leopoldo-Rodado
- Oral and Maxillofacial Surgery, University General Hospital, Valencia, Spain
| | - E Carbonell
- Stomatology, University General Hospital, Valencia, Spain
| | - L Bagán
- Oral Medicine, Valencia University, Spain; University Cardenal Herrera Valencia, Spain
| | - J Utrilla
- Oral Medicine, Valencia University, Spain
| | - C Scully
- University College London [UCL], UK
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