Treatment perspectives for medication-related osteonecrosis of the jaw (MRONJ)

Efficacy of submental island flap closing advanced mandibular MRONJ lesion in malignancy patients

OBJECTIVE

This study evaluated the effectiveness of a submental island flap in closing advanced mandibular medication-related osteonecrosis of the jaw (MRONJ) wounds in patients with malignant tumors.

SUBJECTS AND METHODS

A total of 85 patients with stage II and III MRONJ of mandible with malignant tumor as their primary disease were retrospectively analyzed. All patients underwent surgical treatment, and the soft tissue wound closure was performed either with a submental island flap (SIF) or mucoperiosteal flap (MF). Univariate and multifactorial models were applied to analyze the factors influencing patients' prognosis.

RESULTS

Univariate analysis (p = 0.004, OR 0.075-0.575, 95% CI) and binary logistic regression (p = 0.017, OR 0.032-0.713, 95% CI) suggested that the surgical prognosis of SIF wound closure was significantly better than that of MF.

CONCLUSION

Closure of wound after resection of mandibular MRONJ lesions in patients with malignant tumors using SIF had a better clinical prognosis compared with MF.

Accuracy of the surgical execution of virtually planned deep circumflex iliac artery flaps and their appropriateness for masticatory rehabilitation

BACKGROUND

Tumorous diseases of the jaw demand effective treatments, often involving continuity resection of the jaw. Reconstruction via microvascular bone flaps, like deep circumflex iliac artery flaps (DCIA), is standard. Computer aided planning (CAD) enhances accuracy in reconstruction using patient-specific CT images to create three-dimensional (3D) models. Data on the accuracy of CAD-planned DCIA flaps is scarce. Moreover, the data on accuracy should be combined with data on the exact positioning of the implants for well-fitting dental prosthetics. This study focuses on CAD-planned DCIA flaps accuracy and proper positioning for prosthetic rehabilitation.

METHODS

Patients post-mandible resection with CAD-planned DCIA flap reconstruction were evaluated. Postoperative radiograph-derived 3D models were aligned with 3D models from the CAD plans for osteotomy position, angle, and flap volume comparison. To evaluate the DCIA flap's suitability for prosthetic dental rehabilitation, a plane was created in the support zone and crestal in the middle of the DCIA flap. The lower jaw was rotated to close the mouth and the distance between the two planes was measured.

RESULTS

20 patients (12 males, 8 females) were included. Mean defect size was 73.28 ± 4.87 mm; 11 L defects, 9 LC defects. Planned vs. actual DCIA transplant volume difference was 3.814 ± 3.856 cm³ (p = 0.2223). The deviation from the planned angle was significantly larger at the dorsal osteotomy than at the ventral (p = 0.035). Linear differences between the planned DCIA transplant and the actual DCIA transplant were 1.294 ± 1.197 mm for the ventral osteotomy and 2.680 ± 3.449 mm for the dorsal (p = 0.1078). The difference between the dental axis and the middle of the DCIA transplant ranged from 0.2 mm to 14.8 mm. The mean lateral difference was 2.695 ± 3.667 mm in the region of the first premolar.

CONCLUSION

The CAD-planned DCIA flap is a solution for reconstructing the mandible. CAD planning results in an accurate reconstruction enabling dental implant placement and dental prosthetics.

A Systematic Review of Laser Photobiomodulation Dosimetry and Treatment Protocols in the Management of Medications-Related Osteonecrosis of the Jaws: A Rationalised Consensus for Future Randomised Controlled Clinical Trials

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating adverse effect of bisphosphates, antiresorptive therapy or antiangiogenic agents that can potentially increase oxidative stress, leading to progressive osteonecrosis of the jaws. Despite the large number of published systematic reviews, there is a lack of potential MRONJ treatment protocols utilising photobiomodulation (PBM) as a single or adjunct therapy for preventive or therapeutic oncology or non-oncology cohort. Hence, this systematic review aimed to evaluate PBM laser efficacy and its dosimetry as a monotherapy or combined with the standard treatments for preventive or therapeutic approach in MRONJ management. The objectives of the review were as follows: (1) to establish PBM dosimetry and treatment protocols for preventive, therapeutic or combined approaches in MRONJ management; (2) to highlight and bridge the literature gaps in MRONJ diagnostics and management; and (3) to suggest rationalised consensus recommendations for future randomised controlled trials (RCTs) through the available evidence-based literature. This review was conducted according to the PRISMA guidelines, and the protocol was registered at PROSPERO under the ID CRD42021238175. A multi-database search was performed to identify articles of clinical studies published from their earliest records until 15 December 2023. The data were extracted from the relevant papers and analysed according to the outcomes selected in this review. In total, 12 out of 126 studies met the eligibility criteria. The striking inconsistent conclusions made by the various authors of the included studies were due to the heterogeneity in the methodology, diagnostic criteria and assessment tools, as well as in the reported outcomes, made it impossible to conduct a meta-analysis. PBM as a single or adjunct treatment modality is effective for MRONJ preventive or therapeutic management, but it was inconclusive to establish a standardised and replicable protocol due to the high risk of bias in a majority of the studies, but it was possible to extrapolate the PBM dosimetry of two studies that were close to the WALT recommended parameters. In conclusion, the authors established suggested rationalised consensus recommendations for future well-designed robust RCTs, utilising PBM as a monotherapy or an adjunct in preventive or therapeutic approach of MRONJ in an oncology and non-oncology cohort. This would pave the path for standardised PBM dosimetry and treatment protocols in MRONJ management.

The effectiveness of autologous platelet concentrates in prevention and treatment of medication-related osteonecrosis of the jaws: A systematic review

The systematic review aims to answer the PICOS question: "Are the autologous platelet concentrates (APCs) an effective strategy in prevention and/or treatment of patients at risk of/affected by medication-related osteonecrosis of the jaws (MRONJ)?". A literature search was conducted via PubMed, MEDLINE, EMBASE, and CINAHL (January 2006 - September 2023). 30 articles were included, evaluating preventive (n = 8*) and treatment strategies (n = 23*). The risk of bias and quality of studies were assessed utilising ROB-2, ROBIN-1 and GRADE criteria. Meta-analysis was undertaken for eligible studies. The application of APCs demonstrated a statistically significant effectiveness in prevention of MRONJ in 86.13% (p < 0.001) but failed to achieve the same level of certainty in treatment of established MRONJ in 83.4% (p = 0.08). High levels of bias were identified; thus, the results should be interpreted with caution. More high quality prospective randomised controlled trials are needed to further evaluate the effectiveness of APCs in management of MRONJ.

Raman spectroscopy and U-Net deep neural network in antiresorptive drug-related osteonecrosis of the jaw

OBJECTIVE

Application of an optical method for the identification of antiresorptive drug-related osteonecrosis of the jaw (ARONJ).

METHODS

We introduce shifted-excitation Raman difference spectroscopy followed by U-Net deep neural network refinement to determine bone tissue viability. The obtained results are validated through established histological methods.

RESULTS

Discrimination of osteonecrosis from physiological tissues was evaluated at 119 distinct measurement loci in 40 surgical specimens from 28 patients. Mean Raman spectra were refined from 11,900 raw spectra, and characteristic peaks were assigned to their respective molecular origin. Then, following principal component and linear discriminant analyses, osteonecrotic lesions were distinguished from physiological tissue entities, such as viable bone, with a sensitivity, specificity, and overall accuracy of 100%. Moreover, bone mineral content, quality, maturity, and crystallinity were quantified, revealing an increased mineral-to-matrix ratio and decreased carbonate-to-phosphate ratio in ARONJ lesions compared to physiological bone.

CONCLUSION

The results demonstrate feasibility with high classification accuracy in this collective. The differentiation was determined by the spectral features of the organic and mineral composition of bone. This merely optical, noninvasive technique is a promising candidate to ameliorate both the diagnosis and treatment of ARONJ in the future.

Crystal methamphetamine and its effects on mental and oral health: A narrative review

The purpose of this comprehensive literature review is to present the available evidence on the effects of methamphetamine on mental and oral health, as well as provide an overview of the most widely used medical and dental care strategies in the management of meth mouth. For this purpose, PubMed and Google Scholar electronic databases were searched for relevant articles, yielding 115 search results, which were further scrutinized for their relevance, leaving 55 for a detailed review. The analysis of the gathered data indicates that a comprehensive patient-centered approach that takes into consideration the physical, mental, and social aspects is crucial for mitigating the detrimental effects of increasing methamphetamine use.

A review of oral pathology in orthodontics. Part 2: Pathology of the jaw bones

For many patients, their first full jaw imagining will be requested and reported by an orthodontist. This may lead to the discovery of unexpected pathology in the jaws. In this review article, we discuss the clinical and radiological appearance as well as the pathologic features and treatment of the more common entities of the jaws. In addition, we will discuss the less common lesions which carry important consequences for the patient. Through the identification of these lesions, appropriate referral and management can be pursued.

Medication-Related Osteonecrosis of the Jaw: A Case Report of an Unusual Side Effect of Adalimumab

Background

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse drug reaction characterized by progressive bone destruction and necrosis of mandibular and/or maxillary jaw bone that occurs in patients undergoing treatments with antiresorptive drugs such as bisphosphonates or denosumab, antiangiogenic agents such as bevacizumab, or other kinds of monoclonal antibodies such as rituximab and ipilimumab, for different oncologic and nononcologic diseases. The aim of this study was to report a case of MRONJ in a patient affected by rheumatoid arthritis disease in treatment with adalimumab. Case Presentation. A 70-year-old female patient affected by rheumatoid arthritis (RA), who had been undergoing adalimumab (40 mg subcutaneous injection) every two weeks for 5 years, with no history of antiresorptive or antiangiogenic agent administration, came to our attention for intraoral necrotic bone exposures of the anterior mandible. After drug withdrawal and antibiotic cycles, the patient underwent surgical treatment with bone resection and debridement of necrotic tissues. After an observation period of 8 months, a complete healing without signs of recurrence was detected.

Conclusions

Based on this study, a correlation between adalimumab and MRONJ is possible. Therefore, we believe that an oral cavity examination should be done in every patients, before starting therapy with adalimumab, to possibly avoid MRONJ onset. Further studies are required to confirm the role of adalimumab in MRONJ.

A clinical retrospective study of implant as a risk factor for medication-related osteonecrosis of the jaw: surgery vs loading?

BACKGROUND

Risk factors for developing medication-related osteonecrosis of the jaw (MRONJ) include the general condition of the patient, smoking habit, poor oral hygiene, and the type, duration, and administration route of the drug, dentoalveolar surgery, such as implant placement. This study aimed to discuss whether implants may induce osteonecrosis in older patients receiving long-term medication and to analyze the radiological pattern of the bone necrosis.

METHODS

This study included 33 patients diagnosed with dental implant-associated medication-related osteonecrosis of the jaw. Data regarding the medical history, type of medication used, durations of administration, laboratory test results, onset of bone necrosis since implant placement, type of opposing teeth, and radiological pattern of the bone necrosis on cone-beam computed tomography were recorded in patients with and without implants.

RESULTS

The most commonly used drug was bisphosphonate, with an average duration of use of 61.37 (± 53.72) months. The laboratory results showed average serum C-terminal cross-linking telopeptide (CTX) level of 0.23 ng/mL, vitamin D, 23.42 ng/mL, and osteocalcin, 4.92 ng/mL. Osteonecrosis occurred after an average of 51.03 (± 39.75) months following implant placement. Radiological evaluation revealed obvious sequestration in the implant-absent group, and the formation of a unit sequestration with an implant fixture (en bloc) was observed in the implant-present group. The patients underwent surgical treatment of sequestrectomy and explantation.

CONCLUSION

Implant placement, especially loading, may be considered a potential risk factor for the development of osteonecrosis in patients undergoing antiresorptive treatment.

Multiple-Drugs-Related Osteonecrosis of the Jaw in a Patient Affected by Multiple Myeloma: A Case Report

A 60-year-old woman suffering from multiple myeloma (MM) was treated with zoledronic acid (bisphosphonate), dexamethasone (corticosteroid), bortezomib (a chemotherapeutic agent), and lenalidomide (thalidomide analog) for about a year and with lenalidomide alone as maintenance therapy for almost two years and developed stage three medication-related osteonecrosis of the jaws (MRONJ) in the upper left dental arch approximately two weeks after tooth extraction, which was treated with a medical nonoperative conservative approach until reversion to stage one. The present case report describing the development of multi-drug-related osteonecrosis of the jaws during the pharmacologic MM maintenance phase draws attention to the complex multidisciplinary and multistage management of MM subjects and also that during disease remission, crucially involving oral healthcare providers for MRONJ prevention and pharmacovigilance. To prevent similar cases, cancer patient management should ensure proper dental care not only before starting but also throughout therapy duration and ensure continuous interdisciplinary consensus between oncologists and dentists. Moreover, also considering the independent negative and potentially synergistic effect on bone metabolism and mucosal healing processes of employed medicaments, additionally combined with the cumulative one of previous intravenous bisphosphonates, further studies should highlight the polypharmacy effect and hopefully aid in patient-specific MRONJ risk assessment in cancer patients.

Diagnostic accuracy comparing OPT and CBCT in the detection of non-vital bone changes before tooth extractions in patients with antiresorptive intake

OBJECTIVES

To compare the diagnostic accuracy in detecting early non-vital bone changes between orthopantomography (OPT) and cone-beam computed tomography (CBCT) in correlation with histopathological findings before tooth extractions in patients with antiresorptive (AR) intake.

SUBJECTS

Patients with an indication tooth extraction who had received OPT and CBCT preoperatively while or after undergoing AR treatment were prospectively enrolled over a 24-month period in the progesterone in spontaneous miscarriage (PRISM) trial. Imaging studies were randomly analyzed by three examiners for early non-vital bone changes using specific predefined characteristics and a 5-level scale (1 definite absence of criteria to 5 definite presence of criteria). Sensitivity and specificity values were calculated in correlation with the histopathologically evaluated bone samples at the time point of tooth extraction.

RESULTS

One hundred thirty patients with 237 treated extraction sites met the inclusion criteria. For all images evaluated by all examiners, CBCT (430/492; 87.4%; receiver operating characteristic [ROC]: area under the curve [AUC] = 0.88; p < 0.001) was more likely to detect histopathologically confirmed non-vital bone than the OPT (132/492; 26.8%; ROC: AUC = 0.562; p = 0.115).

CONCLUSIONS

In the detection of non-vital bone changes, CBCT is superior to OPT in both sensitivity and specificity. Specific imaging characteristics allow for the prediction of early non-vital bone changes already at the time before tooth extractions.

Osteoradionecrosis of the Jaw-Comparison between Bone and Soft Tissue Injury and Their Influence on Surgical Outcomes-A Retrospective Cohort Study

Surgical therapy of osteoradionecrosis of the jaw (ORN) is challenging and requires treatment of the affected hard and soft tissue. To understand how tissue injury after irradiation influences surgical outcomes, the objective of this study was to find out whether (a) bone-related, (b) soft tissue-related, and (c) treatment-related parameters influence the surgical success of patients with ORN. A total of 175 patients (324 lesions) were included in this retrospective, single-center study. All patients were diagnosed with ORN and underwent surgical therapy. The primary outcome was complete soft tissue recovery (mucosa/skin) and the absence of symptoms 3 months after surgery. At the time of follow-up, 58% of patients (189 of 324 lesions) had intact intraoral or extraoral soft tissue. The extent of bone destruction had no effect on treatment success, whereas soft tissue injury due to fibrosis (OR: 0.344; CI 0.142-0.834; p = 0.01818) and xerostomia (OR: 0.163; CI 0.064-0.419; p = 0.00016) increased the probability of treatment failure. Soft tissue reconstruction with a microvascular graft improved therapeutic success compared to local wound closure (OR: 2.998; CI 1.371-6.555; p = 0.006). Thus, for the treatment of ORN, it is extremely important to pay attention not only to the extent of bone destruction but especially to soft tissue defects. Because the extent of soft tissue injury is a predictor for therapeutic success, it should influence the choice of surgical treatment.

Evaluation of advanced platelet-rich fibrin (PRF) as a bio-carrier for ampicillin/sulbactam

OBJECTIVES

Mechanisms of wound healing are often impaired in patients with osteonecrosis of the jaw (ONJ). According to the guidelines for the treatment of this disease, early surgical intervention is indicated. However, surgery often faces complications such as wound healing disorders. The application of platelet-rich fibrin (PRF) after necrosectomy between bone and mucosa may constitute a promising approach to improve surgical results. An aspect that was not investigated until now is that PRF acts as a "bio-carrier" for antibiotics previously applied intravenously.

MATERIALS AND METHODS

We investigated the antimicrobial properties of PRF in 24 patients presenting ONJ undergoing systemic antibiosis with ampicillin/sulbactam. We measured the concentration of ampicillin/sulbactam in plasma and PRF and performed agar diffusion tests. Ampicillin/sulbactam was applied intravenously to the patient 10 minutes for blood sampling for PRF. No further incorporation of patients' blood or PRF product with antibiotic drugs was obtained. Four healthy patients served as controls.

RESULTS

Our results revealed that PRF is highly enriched with ampicillin/sulbactam that is released to the environment. The antibiotic concentration in PRF was comparable to the plasma concentration of ampicillin/sulbactam. The inhibition zone (IZ) of PRF was comparable to the standard ampicillin/sulbactam discs used in sensitivity testing.

CONCLUSIONS

The results of our study demonstrated that PRF is a reliable bio-carrier for systemic applied antibiotics and exhibits a large antimicrobial effect.

CLINICAL RELEVANCE

We describe a clinically useful feature of PRF as a bio-carrier for antibiotics. Especially when applied to poorly perfused tissues and bone such as in ONJ, the local release of antibiotics can reduce wound healing disorders like infections.

A comparative study of the clinical characteristics of patients with medication-related osteonecrosis of the jaw and osteoporosis or malignancy

OBJECTIVE

This study aimed to compare the clinical characteristics of patients with medication-related osteonecrosis of the jaw (MRONJ) and osteoporosis vs malignancy.

STUDY DESIGN

The study included patients hospitalized with MRONJ between July 2013 and April 2021. These patients were assigned to the osteoporosis or malignancy groups according to their primary disease. Characteristics and clinical variables were recorded and compared.

RESULTS

Nighty-one patients (107 MRONJ lesions) were included, with 12 (14 lesions) in the osteoporosis group and 79 (93 lesions) in the malignancy group. The osteoporosis and malignancy groups differed in their respective incubation periods (57.0 ± 42.8 vs 29.3 ± 19.8 months, respectively; P = .048), bisphosphonates cumulative dose (16,487.4 ± 14,268.8 mg alendronate vs 104.0 ± 79.9 mg zoledronic; P = .014), and rate of patients receiving antiangiogenic agents (0/12, 0.0% vs 48/79, 60.8%; P = .001). The groups were similar in their treatment outcomes, measured as successful surgeries (11/12, 91.7% vs 59/79, 74.7%; P = .351).

CONCLUSIONS

For stage 2 or 3 MRONJ, patients with osteoporosis (exposed to oral bisphosphonates) developed MRONJ over a longer incubation period than patients with malignancy. The groups had similar responses to surgery.

[Management of medication-related osteonecrosis of the jaw-a review of recent study results in comparison to established strategies]

Hintergrund

Antiresorptiva gehören weltweit zu den am häufigsten applizierten Arzneimitteln. Ihr Haupteinsatzbereich liegt in der Osteologie und Onkologie. Trotz allgemein guter Verträglichkeit treten bei Patienten unter Therapie unerwünschte Arzneimittelwirkungen (UAW) auf. Eine spezifische UAW im Bereich der Kiefer ist die sog. medikamentenassoziierte Osteonekrose („medication-related osteonecrosis of the jaw“, MRONJ) der Kiefer.

Ziel der Arbeit

Diese Arbeit stellt neuesten Entwicklungen in Ätiologie, Diagnostik und Therapie der MRONJ im Vergleich zu bereits bestehenden Erkenntnissen zusammen.

Methodik

Es wurde eine systematische Literaturübersicht der Jahre 2016–2021 zu diesem Thema durchgeführt. Prospektive Therapiestudien, Diagnostikstudien mit Vergleichsgruppe und innovative Studien zur Pathogenese der MRONJ wurden eingeschlossen und nach den MINORS-Kriterien („methodological index for non-randomized studies“) bewertet.

Ergebnisse und Diskussion

Die MRONJ tritt bei ca. 2–12 % der Patienten, die aus onkologischer Indikation mit Antiresorptiva behandelt werden, auf (osteologische Indikation ca. 0,1–1 %). Die Therapie der MRONJ sollte frühzeitig und operativ erfolgen. Die Heilungsrate ist bei einem operativen Therapieansatz mit über 85 % sehr gut.

Risk factors associated with onset of medication-related osteonecrosis of the jaw in patients treated with denosumab

Objectives

While risk factors of bisphosphonate (BP) associated osteonecrosis of the jaw have been properly analyzed, studies focusing on risk factors associated with denosumab (DNO) are sparse. The purpose of this study was to identify risk factors influencing the onset of medication-related osteonecrosis of the jaw (MRONJ) in patients receiving antiresorptive treatment (ART) with DNO by comparing patients suffering from MRONJ and patients without MRONJ. Multiple variables were evaluated including the impact of a previous BP intake.

Materials and methods

A retrospective single-center cohort study with patients receiving DNO was conducted. One-hundred twenty-eight patients were included and divided into three groups: I (control, n = 40) receiving DNO with absence of MRONJ; group II (Test 1, n = 46), receiving DNO with presence of MRONJ; and group III (Test 2, n = 42) sequentially receiving BP and DNO with presence of MRONJ. Patients’ medical history, focusing on the identification of MRONJ risk factors, was collected and evaluated. Parameters were sex, age, smoking habit, alcohol consumption, underlying disease (cancer type, osteoporosis), internal diseases, additional chemo/hormonal therapy, oral inflammation, and trauma.

Results

The following risk factors were identified to increase MRONJ onset significantly in patients treated with DNO: chemo/hormonal therapy (p = 0.02), DNO dosage (p < 0.01), breast cancer (p = 0.03), intake of corticosteroids (p = 0.04), hypertension (p = 0.02), diabetes mellitus (p = 0.04), periodontal disease (p = 0.03), apical ostitis (p = 0.02), and denture use (p = 0.02). A medication switch did not affect MRONJ development (p = 0.86).

Conclusions

Malignant diseases, additional chemotherapy, DNO dosage, and oral inflammations as well as diabetes mellitus and hypertension influence MRONJ onset in patients treated with DNO significantly.

Clinical relevance

Patients receiving ART with DNO featuring aforementioned risk factors have a higher risk of MRONJ onset. These patients need a sound and regular prophylaxis in order to prevent the onset of MRONJ under DNO treatment.

Investigation of the Effectiveness of Surgical Treatment on Maxillary Medication-Related Osteonecrosis of the Jaw: A Literature Review

Aim: Medication-related osteonecrosis of the jaw (MRONJ) occurs after exposure to medication (antiresorptive or antiangiogenic agents) for bone-related complications. It is more common in the mandible than in the maxilla. The present study investigated maxillary MRONJ in elderly patients through a meta-analysis. Methods: Keywords, including “MRONJ”, “maxilla”, and “surgery”, were entered into databases, including Embase, PubMed/MEDLINE, Cochrane Library, and ProQuest, which were searched systematically. Results: Investigating 77 studies, we found that 18 (2 case reports and 16 case series) papers conformed to the standards. The results revealed a 2.6:1 female-to-male ratio of disease occurrence. The average age of patients was 70.6 ± 5.5 years, and most patients were in the third stage (43.6%). The average time of medication usage was 50.0 ± 20.1 months. The pooled proportion of clinical efficacy of surgery was 86%. Conclusion: To prevent and manage MRONJ, all elderly patients should maintain proper oral hygiene and receive dental examinations regularly. Risk assessment and safety management of MRONJ should be performed by medical teams.

Conservative Management of Severe Medication-Related Osteonecrosis of the Jaw With Pathological Fracture

ABSTRACT

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known risk following dental extraction in patients taking certain medications. Pathological fracture secondary to MRONJ often requires complex operative intervention.This case demonstrates the conservative management of pathological fracture secondary to MRONJ in a patient with multiple comorbidities. The patient developed MRONJ with pathological fracture following extraction of the mandibular second molar. The patient presented with significant surgical risk factors, having hypertension and a recent stroke, causing dense left hemiparesis, subsequently resulting in transition to high-level nursing care. Given the high risk of reconstructive surgery, nonoperative management was undertaken. Following a course of long-term antibiotics with resolution of signs of infection, the case was managed conservatively with chlorhexidine-based mouthwash and soft diet.With routine clinico-radiographic assessment and optimal oral health care, the pathological fracture did not require operative intervention. Healing progressed well with no clinical complications and radiographic evidence of good healing at 6- and 12-month follow-up on orthopantomogram.A role for conservative management of pathological fractures secondary to MRONJ yet exists, especially in the elderly population. This case highlights the importance of developing treatment plans based on individual patient context and clinical assessment.

A retrospective study on the incidence of medication-related osteonecrosis of the jaws (MRONJ) associated with different preventive dental care modalities

Purpose

To assess the efficacy of different preventive dental visits and treatments in reducing the risk of medication-related osteonecrosis of the jaws (MRONJ).

Methods

In this retrospective study, patients diagnosed with MRONJ were divided into 5 groups based on available data: no preventive dental visits (group 0); dental visits and compliance with recommended treatments, at the university hospital’s dental clinic (group 1) or maxillofacial surgery unit (group 2), or at a private dentist’s (group 3); dental visits at one of the above and noncompliance with proposed treatments (group 4); patients judged eligible by the oncologist on panoramic radiography (group 5). Patients were classified on severity of MRONJ according to the Italian SIPMO/SICMF 2.0 staging system. A descriptive analysis was performed on the results. Fisher’s exact test was applied (p < 0.05).

Results

Ninety-three patients diagnosed with MRONJ were considered for the study, but 22 were excluded due to a lack of data, leaving a sample of 71 cases. MRONJ staging was only 0 for some patients (26.92%) in group 0. In all groups, the majority of patients had stage 2 MRONJ. The proportions of cases in stage 3 were 7.69% in group 0, 18.18% in group 3, and 43.48% in group 5. Groups 0 and 3 were somewhat similar as regard MRONJ staging. Most patients in group 5 had MRONJ stage 2 or 3. No statistically significant differences emerged between the groups.

Conclusions

Preventive dental care can reduce the risk of MRONJ providing patients comply with the specialist’s recommendations.

Different Presentation and Outcomes in the Surgical Treatment of Advanced MRONJ in Oncological and Nononcological Patients Taking or Not Corticosteroid Therapy

Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect caused by antiangiogenic antiresorptive drugs used to treat various oncological and non oncological diseases. The clinical and radiological characteristics of MRONJ depend on the type of causative drug, the time of administration, and its dosage. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases (e.g., high doses of methotrexate up to 30 mg daily) significantly increase the chances of acquiring MRONJ. The risk factors themselves can affect treatment outcomes. Although the main scientific societies have recently disseminated good practice rules on the patient's prevention, diagnosis, and management, there are still no guidelines on shared therapeutic strategies. In general, if conservative treatment fails, surgical treatment is considered, including local debridement, osteoplasty, and marginal or segmental osteotomy. In literature, cohorts of heterogeneous patients with MRONJ have been analyzed for a long time, resulting in a lack of uniformity of information and difficulties interpreting the data. According to the American Association of Oral and Maxillofacial Surgeons criteria, this retrospective study evaluates the surgical treatment outcomes of 64 patients with stage II-III MRONJ, evaluated at the Department of Maxillofacial Surgery of the University of Turin (Italy). The first objective of this retrospective study is to evaluate treatment results for stages II-III in all cases; the second objective is to evaluate the same results by dividing the sample into different cohorts of patients: first, based on the underlying pathology, i.e., oncological and non oncological, and secondly, based on the drug or combination of drugs they took.

Analysis of Factors Associated with the Postoperative Healing of Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

BACKGROUND

Surgical treatment is considered the best approach by many researchers for medication-related osteonecrosis of the jaws (MRONJ). While postoperative outcomes are mainly favorable, wound healing still fails in some cases. This retrospective study aimed to evaluate the factors affecting the postoperative healing of MRONJ.

METHODS

This study involved 400 osteoporosis patients who received surgical treatment from January 2009 to January 2018 in Kyungpook National University Hospital. The patient, drug, and clinical factors were collected as investigation variables. The obtained data were statistically analyzed to identify relationships between the factors and healing aspect.

RESULTS

Univariate logistic regression analysis showed that the route of drug administration, bone exposure, types of surgical management, and wound management had a significant influence (p < 0.05) on the healing outcome. Sequestrectomy with primary closure had a more positive effect on favorable healing. In the multivariate logistic regression test, the effect of wound management alone was not statistically significant (p > 0.05).

CONCLUSION

In patients with osteoporosis, the factors such as intravenously administered drugs, fistulas that were probed to the bone, and surgical management with curettage were associated with a lower rate of postoperative complete healing of MRONJ, whereas primary closure of wounds led, possibly, to good healing outcomes. The strengths of the study include its relatively large sample size and that its results can hopefully aid in the clinical decisions for practitioners and future research studies for researchers.

Treatment of Refractory Medicine Related Osteonecrosis of Jaw With Piezosurgical Debridement and Autologous Platelet Rich Fibrin: Feasibility Study

ABSTRACT

Medicine related osteonecrosis of jaw (MRONJ) is incidental in patients receiving certain bone modifying agents in oncology. These lesions may not respond to conservative management and aggravate. Autologous platelet derivatives contain bone growth factors, which help in bone regeneration. The aim of this pilot study is to develop protocol for treatment of refractory MRONJ with pizosurgical debridement and advanced platelet rich fibrin.In this feasibility study, refractory MRONJ lesions were treated by piezosurgical debridement and insertion of autologous advanced platelet rich fibrin in 15 patients. One patient had 2 lesion sites, so in all 16 MRONJ sites were treated. These patients were evaluated at the end of 1 month and 4 months for healing of MRONJ lesion. Statistical analysis was done by using Fisher test for response assessment in relation to variable. Eight lesions (50%) showed complete healing at the end of 1 month. At the end of 4 months 13 lesions (81.50%) were completely healed, 2 lesions (12.5%) were downgrades, and 1 lesion (6.25%) did not respond to treatment. Number of doses of bone modifying agent was only factor found associated with nonhealing of MRONJ when treated with this protocol.In this pilot study, feasibility of use of piezosurgical debridement and platelet rich fibrin was evaluated. The results of the study suggest complete healing can be achieved with this treatment protocol. Further research with increased sample size is warranted to determine optimum use of autologous platelet concentrates in treatment of MRONJ.

Infection as an Important Factor in Medication-Related Osteonecrosis of the Jaw (MRONJ)

Medication-related osteonecrosis of the jaw (MRONJ) has become a well-known side effect of antiresorptive, and antiangiogenic drugs commonly used in cancer management. Despite a considerable amount of literature addressing MRONJ, it is still widely accepted that the underlying pathomechanism of MRONJ is unclear. However, several clinical and preclinical studies indicate that infection seems to have a major role in the pathogenesis of MRONJ. Although there is no conclusive evidence for the infection hypothesis yet, available data have shown a robust association between local infection and MRONJ development. This observation is very critical in order to implement policies to reduce the risk of MRONJ in patients under antiresorptive drugs. This critical review was conducted to collect the most reliable evidence regarding the link between local infection and MRONJ pathogenesis.

Combined approach to treatment of advanced stages of medication-related osteonecrosis of the jaw patients

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Removal of necrotic bone is important in the treatment of medication- related osteonecrosis of the jaw.

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Surgical treatment is more successful than conservative treatment in advanced stages (stage 2–3) of the medication- related osteonecrosis of the jaw.

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Relatively less invasive and supportive treatments are recommended in patients with advanced medication- related osteonecrosis of the jaw.

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Patient follow-up, good oral hygiene and patient motivation increase the success rate of the treatment.

Introduction

Increased incidence of localized osteonecrosis in the jaw bones caused by bisphosphanate use and reduced quality of life of the patients led researchers to diagnose the disease in the early period and to investigate the effective treatment modality.

Objective

Treatment of medication-related osteonecrosis of the jaw patients is based on individual protocols from clinical experience, as there are no definitive treatment guidelines. In view of the lack of consensus on the effectiveness of medication-related osteonecrosis of the jaw treatments in the literature, the aim of this study was to evaluate the surgical technique described in the treatment of advanced stages of medication-related osteonecrosis of the jaw patients.

Methods

Twenty-one patients affected by Stage 2–3 medication-related osteonecrosis of the jaw were treated with ultrasonic piezoelectric bone surgery for necrotic bone removing, leukocyte and platelet-rich fibrin concentrate obtained from the patient’s peripheral blood and Nd:YAG laser for biostimulation. Success was assessed as the maintenance of full mucosal coverage without signs of residual infection at 1-month (T1), 3-months (T2), 6-months (T3) and 1-year (T4) after surgery. Logistic regressions were used to evaluate the association between the different independent variables and treatment outcomes.

Results

Two Stage 3 patients had delayed healing at 1 month after the operation. Complete mucosal healing was achieved in all patients at the third month. Multivariate analysis demonstrated that different variables were not significantly correlated with delayed healing (p > 0.05).

Conclusion

The surgical protocol presented in this study shows promising results for surgical management of advanced stages of medication-related osteonecrosis of the jaw patients.

Photodynamic Therapy for Biomodulation and Disinfection in Implant Dentistry: Is It Feasible and Effective?

Dental implants are the most common rehabilitation and restorative treatment used to replace missing teeth. Biofilms adhere to implant surfaces to trigger implant-associated infection and inflammatory response. Clinically, the biofilm induces a local host response with the infiltration of phagocytic immune cells. The pro-inflammatory surroundings set off osteoclastogenesis, which leads to the septic loosening of the implant. The standard of dental care for implant-associated infection relies on a combination of surgery and antimicrobial therapy. Antimicrobial photodynamic therapy is a noninvasive and photochemistry-based approach capable of reducing bacterial load and modulating inflammatory responses. In this review, we explore the photobiomodulation and disinfection outcomes promoted by photodynamic therapy for implant infections, highlighting the quality of evidence on the most up-to-date studies, and discuss the major challenges on the advance of these therapeutic strategies.

The awareness and practice of dentists regarding medication-related osteonecrosis of the jaw and its prevention: a cross-sectional survey

Background

Accurate documentation of a patient’s prior medication use and awareness of side effects associated with anti-osteoporotic agents can assist dentists to prevent medication-related osteonecrosis of the jaw. I aimed to determine the awareness of Korean dentists regarding medication-related osteonecrosis of the jaw and the duration of drug holidays they prescribe to patients who need to undergo various dental procedures.

Methods

An online, questionnaire-based survey was conducted among 1000 dentists registered in an online community in Korea. The following were determined: general characteristics; type of practice; recordkeeping regarding patients’ use of bone-modifying agents; requirement of a doctor’s referral letter; advice given regarding drug holidays of bone-modifying agents before dental surgery procedures; and experience with medication-related osteonecrosis of the jaw. Differences between dentists with and without experience in treating patients with medication-related osteonecrosis of the jaw were evaluated using the χ² test.

Results

Although a relatively high proportion (293/1000, 29.3%) of dentists had experienced cases of medication-related osteonecrosis of the jaw, only 650/1000 (65.0%) routinely documented the type of bone-modifying agent used by patients and the duration of its use. Moreover, only 591/1000 (59.1%) dentists routinely requested referral letters from doctors before performing dental surgery on patients. Although the recommended period for a drug holiday differs for each drug, 533/1000 (53.3%) dentists did not make such a distinction. There was a statistically significant difference in the level of detail documented in terms of anti-osteoporotic drug use between dentists who had no experience in medication-related osteonecrosis of the jaw (707/1000) and those who had such experience (P = 0.007). There was a statistically significant difference in the length of drug holidays prescribed between dentists with and without prior experience with the condition (P = 0.001).

Conclusions

These results suggest that dentists do not respond consistently to patients' drug history prior to performing dental procedures. This implies the need for increased cooperation between dentists and physicians, as well as the development of targeted educational interventions for the dental profession, to reduce the risk of medication-related osteonecrosis of the jaw.

Trial registration

Not applicable.

Supplementary information

The online version contains supplementary material available at 10.1186/s12903-021-01475-6.

On the effect of antiresorptive drugs on the bone remodeling of the mandible after dental implantation: a mathematical model

Bone remodeling identifies the process of permanent bone change with new bone formation and old bone resorption. Understanding this process is essential in many applications, such as optimizing the treatment of diseases like osteoporosis, maintaining bone density in long-term periods of disuse, or assessing the long-term evolution of the bone surrounding prostheses after implantation. A particular case of study is the bone remodeling process after dental implantation. Despite the overall success of this type of implants, the increasing life expectancy in developed countries has boosted the demand for dental implants in patients with osteoporosis. Although several studies demonstrate a high success rate of dental implants in osteoporotic patients, it is also known that the healing time and the failure rate increase, necessitating the adoption of pharmacological measures to improve bone quality in those patients. However, the general efficacy of these antiresorptive drugs for osteoporotic patients is still controversial, requiring more experimental and clinical studies. In this work, we investigate the effect of different doses of several drugs, used nowadays in osteoporotic patients, on the evolution of bone density after dental implantation. With this aim, we use a pharmacokinetic-pharmacodynamic (PK/PD) mathematical model that includes the effect of antiresorptive drugs on the RANK/RANK-L/OPG pathway, as well as the mechano-chemical coupling with external mechanical loads. This mechano-PK/PD model is then used to analyze the evolution of bone in normal and osteoporotic mandibles after dental implantation with different drug dosages. We show that using antiresorptive agents such as bisphosphonates or denosumab increases bone density and the associated mechanical properties, but at the same time, it also increases bone brittleness. We conclude that, despite the many limitations of these very complex models, the one presented here is capable of predicting qualitatively the evolution of some of the main biological and chemical variables associated with the process of bone remodeling in patients receiving drugs for osteoporosis, so it could be used to optimize dental implant design and coating for osteoporotic patients, as well as the drug dosage protocol for patient-specific treatments.

Emerging therapies with potential risks of medicine-related osteonecrosis of the jaw: a review of the literature

In the past, osteonecrosis of the jaw (ONJ) was generally reported with bisphosphonate drugs; hence, the term BRONJ (bisphosphonate-related osteonecrosis of the jaw) was initially proposed. This was followed by the term ARONJ (antiresorptive osteonecrosis of the jaw). More recently, other novel medications such as vascular endothelial growth factor (VEGF) inhibitors, tyrosine kinase inhibitors and humanised antibodies that affect osteoclastic action have been reported to initiate ONJ in several cases. For this reason, in 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) changed the term to MRONJ - medication-related osteonecrosis of the jaw. The review primarily focuses on ONJ associated with emerging therapies for the management of bone disorders. This article sheds some light on the risk factors that predispose dental patients to the development of osteonecrosis, the mechanisms of drug therapies associated with MRONJ, and potential treatment and management regimes for MRONJ patients. The current review noted that the incidence and associated risk of MRONJ is significant with the new therapeutic agents discussed. Therefore, for optimised patient care, pharmacovigilance with the new medications is essential for dental professionals.

Surgical strategy for medication-related osteonecrosis of the jaw (MRONJ) on maxilla: A multicenter retrospective study

Background/purpose

Because the anatomy and the nature of the bone tissue between the mandible and maxilla are largely different, more site-specific studies are required to improve the healing rate on medication-related osteonecrosis of the jaw (MRONJ). The present study assessed maxillary MRONJ that was treated by surgery to understand its clinical characteristics, and to identify critical factors that influenced outcomes.

Materials and methods

The medical records of 54 patients with maxillary MRONJ who underwent surgery were retrospectively reviewed. Variables related to the prognosis of MRONJ were extracted from the medical records and imaging, and were statistically analyzed. We also evaluated the concomitant maxillary sinusitis (MS) after the surgical treatment of MRONJ, based on CT evaluation and change of symptoms.

Results

The healing rate of surgery for maxillary MRONJ was 85.2%, which suggested that surgical treatment is an effective strategy for treating maxillary MRONJ. Multivariate analysis revealed that postoperative residual necrotic bone was a poor prognosticator for maxillary MRONJ. Among 10 patients who did not obtain healing of MS postoperatively, 8 patients showed an improvement.

Conclusion

Our results indicate that surgical treatment is an appropriate strategy for maxillary MRONJ and complete resection of necrotic bone (i.e., extensive surgery) is needed to obtain complete healing of maxillary MRONJ. Concomitant MS tends to be healed or improved clinically in combination with the healing of maxillary MRONJ.

Concentration of Penicillin G in Jawbone Affected by Antiresorptive Agent-Related Osteonecrosis Following a Single Preoperative Dose

The aim of this study was to evaluate the concentration of penicillin G in bone affected by antiresorptive agent-related osteonecrosis of the jaw (ARONJ) following a single preoperative dose of 10 million international units (6000 mg). ARONJ is a major concern in patients administered antiresorptive agents for conditions associated with pathologically increased bone resorption. Antibiotic therapy is a key component of most treatment approaches for ARONJ and penicillin based regimens, providing a cost effective therapy option with a favorable side effect profile, are administered most frequently. In this study, high performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS) was applied to evaluate penicillin G concentration in serum and bone samples of 19 patients suffering from ARONJ and undergoing surgical treatment under perioperative intravenous (IV) antibiotic therapy. Penicillin G bone concentrations were above the limit of detection (0.1 μg/g bone tissue) in 16 out of 19 samples, with a median concentration of 2.7 μg/g (range 0.1–8.8 μg/g). Penicillin G concentrations in intraoperative serum samples were above the limit of detection in all serum samples, with a median concentration of 116 μg/mL (range 1–232 μg/mL). Thus, considering bacteria frequently found in ARONJ lesions, penicillin G at levels providing adequate antimicrobial activity was detected in the serum and 16 out of 19 osteonecrotic lesions of patients suffering from ARONJ.

The Case of Medication-Related Osteonecrosis of the Jaw Addressed from a Pathogenic Point of View. Innovative Therapeutic Strategies: Focus on the Most Recent Discoveries on Oral Mesenchymal Stem Cell-Derived Exosomes

Bisphosphonates-related osteonecrosis of the jaw (BRONJ) was firstly reported by Marx in 2003. Since 2014, the term medication-related osteonecrosis of the jaw (MRONJ) is recommended by the American Association of Oral and Maxillofacial Surgeons (AAOMS). Development of MRONJ has been associated to the assumption of bisphosphonates but many MRONJ-promoting factors have been identified. A strong involvement of immunity components has been suggested. Therapeutic intervention includes surgical and non-surgical treatments, as well as regenerative medicine procedures for the replacement of the lost tissues. The literature confirms that the combination of mesenchymal stem cells (MSCs), biomaterials and local biomolecules can support the regeneration/repair of different structures. In this review, we report the major open topics in the pathogenesis of MRONJ. Then, we introduce the oral tissues recognized as sources of MSCs, summing up in functional terms what is known about the exosomes release in physiological and pathological conditions.

The Type of Antiresorptive Treatment Influences the Time to Onset and the Surgical Outcome of Medication-Related Osteonecrosis of the Jaw

PURPOSE

Few data exist focusing on differences in the time to disease onset and the success rates in patients suffering from medication-related osteonecrosis of the jaw (MRONJ) dependent on their different antiresorptive treatment. The purpose of this study was to analyze and compare these variables for patients treated with bisphosphonate (BP) or denosumab (DNO) and for patients who switched the antiresorptive drug (BP/DNO).

PATIENTS AND METHODSS

A retrospective single-center cohort study with patients suffering from MRONJ was conducted. The predictor variable was the antiresorptive treatment, the outcome variables were 1) time to onset of MRONJ (time of antiresorptive treatment to MRONJ diagnosis) and 2) treatment success (mucosal integrity 12 months postoperatively). The other variables include data on demographic, underlying disease, MRONJ stage, and trigger events. Cox and logistic regression, Phi-coefficient, Cramer's V, and Kruskal-Wallis tests were applied.

RESULTS

One hundred thirty-two patients were included and divided into 3 groups: group I (BP) n = 45 patients, n = 59 lesions; group II (BP/DNO) n = 42 patients, n = 71 lesions; and group III (DNO) n = 45 patients, n = 62 MRONJ lesions. Treatment success and time to onset differed significantly between the groups: success rates in group I BP (84.7%) were significantly lower (P = .04) than in group II BP/DNO (91.5%, P = .12) and group III DNO (90.3%, P = .35). The onset was significantly earlier in group III DNO (median 2.0 years, Q_0.25: 1.49, Q_0.75: 2.98; confidence interval 95%: 1.93 to 2.83) than in group II BP/DNO (median 4.07 years, Q_0.25: 1.64, Q_0.75: 6.70; confidence interval 95%: 3.55 to 5.68) and group I BP (median 3.86 years, Q_0.25: 1.69, Q_0.75: 6.46; confidence interval 95%: 3.43 to 5.87).

CONCLUSIONS

The different antiresorptive drugs show distinctive characteristics of time to onset and treatment success with the lowest success rates in the BP group and the earliest onset in the DNO group. The switch of the antiresorptive therapy (BP to DNO) did not influence the outcome variables negatively.

Management of Medication-Related Osteonecrosis of the Jaw (MRONJ) Using Leukocyte- and Platelet-Rich Fibrin (L-PRF) and Photobiomodulation: A Retrospective Study

Background. The aim of this study was to compare retrospectively the effect of three different treatment protocols on the healing outcome in patients with established medication-related osteonecrosis of the jaw (MRONJ). Methods. A total of 34 MRONJ patients were recruited from the Department database and were divided according to the treatment protocols in a study group (G1) and two control groups (G2 and G3). G1 was treated with antibiotic therapy, surgery, leukocyte- and platelet-rich fibrin (L-PRF), and photobiomodulation; G2 was treated with antibiotic therapy and surgery; G3 was treated with antibiotic therapy and photobiomodulation. Various clinical variables and treatment protocols were analyzed to determine their correlation with the healing outcome at three and six months of follow-up. Results. There was a significant association between the different treatment protocols and the outcomes at both three and six months follow-up (p = 0.001 and p = 0.002, respectively). No significant association was observed between the outcomes and MRONJ localization, MRONJ stage, duration of drug treatment, gender, diabetes, corticosteroid therapy, smoking habits, underlying disease, and history of chemotherapy at both three and six months follow-up. Conclusions. Our results show that the combination of antibiotic therapy, surgery, L-PRF, and photobiomodulation may effectively contribute to MRONJ management.

In Vivo Regeneration of Large Bone Defects by Cross-Linked Porous Hydrogel: A Pilot Study in Mice Combining Micro Tomography, Histological Analyses, Raman Spectroscopy and Synchrotron Infrared Imaging

The transplantation of engineered three-dimensional (3D) bone graft substitutes is a viable approach to the regeneration of severe bone defects. For large bone defects, an appropriate 3D scaffold may be necessary to support and stimulate bone regeneration, even when a sufficient number of cells and cell cytokines are available. In this study, we evaluated the in vivo performance of a nanogel tectonic 3D scaffold specifically developed for bone tissue engineering, referred to as nanogel cross-linked porous-freeze-dry (NanoCliP-FD) gel. Samples were characterized by a combination of micro-computed tomography scanning, Raman spectroscopy, histological analyses, and synchrotron radiation-based Fourier transform infrared spectroscopy. NanoCliP-FD gel is a modified version of a previously developed nanogel cross-linked porous (NanoCliP) gel and was designed to achieve highly improved functionality in bone mineralization. Spectroscopic imaging of the bone tissue grown in vivo upon application of NanoCliP-FD gel enables an evaluation of bone quality and can be employed to judge the feasibility of NanoCliP-FD gel scaffolding as a therapeutic modality for bone diseases associated with large bone defects.

Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care.

METHODS

We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals.

RESULTS

While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ.

CONCLUSIONS

This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.

Wound closure and alveoplasty after preventive tooth extractions in patients with antiresorptive intake-A randomized pilot trial

OBJECTIVES

To compare success rates between the sub-periosteal prepared (SPP) muco-periosteal flap and the epi-periosteal prepared (EPP) mucosa flap and the feasibility of alveoplasty after surgical tooth extractions in patients undergoing/after antiresorptive treatment.

SUBJECTS

Patients with an indication for preventive tooth extraction undergoing/after antiresorptive treatment were enrolled over a 24-month period in a parallel-group randomized clinical pilot trial and randomly assigned for primary wound closure to either the SPP or the EPP group. The primary outcome was treatment failure 8 weeks after surgery. To assess the feasibility of alveoplasty, necrotic bone changes at the time point of tooth extraction were evaluated.

RESULTS

One hundred and sixty patients were randomized to the SSP (n = 82) or the EPP (n = 78) group. One hundred and fifty-seven patients met the primary endpoint 8 weeks after surgery with five treatment failures for the SPP group (6.3%) and 18 (23.4%) for the EPP group (p = .004). A significant relationship (p < .0001) was observed between symptomatic teeth and non-vital bone found in 54.8% of all biopsies.

CONCLUSIONS

The strong superiority of the muco-periosteal flap as primary wound closure revealed the feasibility and effectiveness of the study. The large number of necrotic biopsies emphasizes the importance of alveoplasty as a preventive measure.

Prevention of medication related osteonecrosis of the jaw after dentoalveolar surgery: An institution's experience

Background

Dentoalveolar surgery is a predisposing factor for medication related osteonecrosis of the jaw (MRONJ). The aim of our study was to evaluate the described surgical procedures to prevent the development of MRONJ after dentoalveolar surgery in patients receiving bisphosphonates.

Material and Methods

In this retrospective study, sixty-three dentoalveolar surgeries were performed on 44 patients taking bisphosphonate in accordance with the treatment procedures we described. The following procedures were applied to patients 1) use of antibiotics 2) performed dentoalveolar surgical procedures 3) fill the socket with leukocyte- and platelet-rich fibrin (L-PRF) 4) post-operative application of low level laser therapy through Nd: YAG laser 5) sutures were removed on post-op 14th day 6) long-term results were evaluated.

Results

Healing of all patients was uneventful. Complete mucosal healing was achieved in all patients at 1 month. There is no failure was observed in long-term follow-up.

Conclusions

Because of the pathophysiology of MRONJ is not fully understood and has many risk factors, definitive protocols on prevention and treatment have not been established yet. Personal risk assessment is required for the prevention and treatment of MRONJ. The described surgical protocol may be considered to reduce the risk of developing MRONJ after dentoalveolar surgery due to its high success rate.

Key words:Tooth extraction, medication related osteonecrosis of the jaw, preventive dentistry, L-PRF, low level laser therapy.

Surgical treatment of advanced medication-related osteonecrosis of the jaws: Comparison of soft tissue closure techniques and evaluation of side effects

The aim of the study was to evaluate the surgical outcome of patients with advanced medication-related osteonecrosis of the jaw (MRONJ) treated with different flaps for soft tissue closure. Only MRONJ stage III patients with a minimum follow-up of 6 months were included in our prospective study. The soft tissue closure techniques were: Mylohyoid Muscle Flap, Buccal Fat Flap and mucoperiosteal flap alone. Potential risk factors and surgical side effects were analyzed. Relapses occurred in 12 of 44 included cases and 38 reached mucosal integrity within the follow-up. Cases treated with the muscle or fat flap showed better results regarding the recurrence rate (p < 0.001) and soft tissue healing (p = 0.002): only 3 of 33 developed a relapse, and 31 of 33 reached mucosal integrity. The outcome was worse if MRONJ occurred at the front areas of the jaw (p = 0.025). Postoperative, the pain level was reduced significantly (p < 0.001). Partial hypoesthesia of the lip arose in 18 cases. An impairment of the long-term prosthetic rehabilitation has not been seen.Patients with MRONJ stage III undergoing surgery benefit from extensive soft tissue closure.

Conservative non-surgical management in medication related osteonecrosis of the jaw: A retrospective study

Objectives

To date, the best treatment for Medication Related Osteonecrosis of the jaw (MRONJ) is controversial. Recent studies suggest different therapies, considering the stage of MRONJ; however, sometimes patients, although with remarkable extension of disease, cannot undergo surgery. The purpose of present preliminary study was to evaluate the efficacy of conservative non‐surgical treatment of MRONJ lesions in a cohort of patients ineligible for surgery or refusing any surgical treatment for stage II and III of MRONJ.

Materials and methods

Patients with MRONJ (staging II or III) ineligible for surgical treatment were selected for a retrospective study. A conservative non‐surgical therapy (antibiotics and antiseptic) was administered for 1 year. Five scheduled checks were performed to assess changes in signs and symptoms during the observational period.

Results

Our observation was carried out on 12 patients. Improvement of signs and symptoms of disease were observed in population.

Conclusion

This study suggests that non‐surgical treatment may be a valid therapeutic option in patients ineligible for surgery. The sample size is small, further studies should be carried out to satisfy the aim of a conservative non‐surgical treatment protocol establishment.

A Retrospective Observational Study of Risk Factors for Denosumab-Related Osteonecrosis of the Jaw in Patients with Bone Metastases from Solid Cancers

This single-center retrospective observational study aimed to identify risk factors for developing denosumab-related osteonecrosis of the jaw (DRONJ) in stage IV solid cancer patients with bone metastases. In total, 123 consecutive patients who had received 120 mg of denosumab every 4 weeks at least twice between July 2014 and October 2018 were included. We surveyed their demographics, medical history, blood test, underlying disease, and intraoral findings. Fourteen patients (11.4%) developed DRONJ within a mean denosumab administration period of 4 months (range: 2-52 months). Univariate analyses showed a statistically significant correlation between DRONJ and hormone therapy, chemotherapy/molecular target drug, apical periodontitis, periodontal disease, sex and body mass index. Multivariate analysis showed a statistically significant correlation between DRONJ and hormone therapy (odds ratio [OR], 22.07; 95% confidence interval [CI], 2.86-170.24), chemotherapy and/or molecular targeted therapy (OR, 18.61; 95% CI, 2.54-136.27), and apical periodontitis (OR, 22.75; 95% CI, 3.20-161.73). These findings imply that collaborative oral examinations by oral specialists may reduce the risk of development of DRONJ in patients treated with denosumab for bone metastases from solid cancers.

Prevention Of Skeletal Related Events In Multiple Myeloma: Focus On The RANK-L Pathway In The Treatment Of Multiple Myeloma

More than 90% of patients with multiple myeloma (MM) have osteolytic bone lesions which increase the risk of skeletal-related events (SRE). The cytokine milieu in the bone marrow microenvironment (BMME) of MM plays a key role in myeloma bone disease by impairing the balance between osteoclastogenesis and osteoblastogenesis. This is orchestrated by the malignant plasma cell (MPC) with the ultimate outcome of MPC proliferation and survival at the expense of excess osteoclast activation resulting in osteolytic bone lesions. Prevention of SRE is currently accomplished by the inhibition of osteoclasts. Bisphosphonates (BPs) are pyrophosphate analogues that cause apoptosis of osteoclasts and have been proven to prevent and delay SRE. Denosumab, a fully humanized monoclonal antibody that binds and inhibits receptor activator of nuclear factor-ĸB ligand (RANKL), a key molecule in the BMME crucial for osteoclastogenesis, is also approved for the prevention of SRE in MM. The addition of BPs and denosumab to standard MM treatment affords a survival benefit for patients with MM. Specifically, the addition of denosumab to standard MM treatments results in superior PFS compared to BPs, highlighting the key role of the RANKL pathway in MM. This review focuses on the pathophysiology of myeloma bone disease as well as on the importance of targeting the RANK-L pathway for the treatment of MM and prevention of SRE.

Is the conservative non-surgical management of medication-related osteonecrosis of the jaw an appropriate treatment option for early stages? A long-term single-center cohort study

PURPOSE

No consensus has been reached regarding the best treatment option for early-stage lesions in medication-related osteonecrosis of the jaw (MRONJ). The purpose of the present study was to evaluate the long-time outcomes of conservative non-surgical management in stage I patients with underlying malignant disease.

MATERIALS AND METHODS

We designed and implemented a retrospective cohort study and enrolled, between 2008 and 2018, a sample of patients with the indication for non-surgical conservative treatment stage I lesions. The primary outcome variable was treatment success defined as mucosal integrity without signs of infection. Secondary outcomes were: (i) worsening stage, (ii) necessity for surgical intervention over time, and (iii) discontinuation of antiresorptive therapy.

RESULTS

The sample included 75 patients with 92 lesions. Eight lesions showed full mucosal coverage, whereas 84 continued with exposed jaw bone (91.3%). Of the treatment-resistent 84 lesions, 67 presented a worsening stage shift over time. Indication for surgical intervention was set in 57 lesions. Of all lesions, 28 developed highly advanced necrotic bone destruction. Antiresorptive medication was paused in all evaluated patients after the first diagnosis of MRONJ.

CONCLUSION

Conservative non-surgical therapy in MRONJ stage I leads to a healing in rare cases. Conservative management might be a good option to preserve symptoms in patients either unwilling to undergo surgery or in those whose reduced general condition does not allow surgery. Early and consequent surgical advances should be performed throughout all stages of the disease to prevent the possibility of silent disease progression with the risk of large-scale bone loss.