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D’Agostino S, Valentini G, Dolci M, Ferrara E. Potential Relationship between Poor Oral Hygiene and MRONJ: An Observational Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5402. [PMID: 37048016 PMCID: PMC10094150 DOI: 10.3390/ijerph20075402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 06/19/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a drug-related side effect linked but not limited to antiresorptive and antiangiogenic molecules. It recognizes several triggers in dental procedures, such as surgery, endodontic treatments, and root planing, but also prosthesis decubitus or with a spontaneous onset. Although there are many reports about the onset of this pathology, oral hygiene status is mainly described as a consequence of MRONJ. Not so much is known about the oral hygiene situation as a concurrent factor in the pathogenesis of severe stages and about non-surgical periodontal therapy in patients affected by MRONJ. Actually, clear instructions for non-surgical periodontal therapy are poor in the literature. The primary outcome of the present study is to evaluate the oral hygiene status in MRONJ patients. In addition, a secondary outcome is to review the factor of poor oral hygiene as a cause or worsening aspect for MRONJ. A total of 45 subjects (19 males and 26 females) with a mean age of 59 ± 12 were enrolled. The Pearson correlation coefficient showed no significant results for the variable of the Simplified Oral Hygiene Index (OHI-S) and the American Association of Oral and Maxillofacial Surgeons (AAOMS) stage, although the majority of patients showed poor oral hygiene with an OHI-S average of 3.39 ± 1.83. As stated by the last AAOMS position paper, poor plaque control is related to a worsened MRONJ stage. The relation between the lack of oral hygiene and MRONJ onset is still unclear.
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Affiliation(s)
- Silvia D’Agostino
- Complex Unit of Odontostomatology, Interdisciplinary Department of Medicine, University Aldo Moro of Bari, 70121 Bari, Italy
- Department of Medical, Oral and Biotechnological Sciences, University Gabriele d’Annunzio, 66100 Chieti, Italy
| | - Giulia Valentini
- Department of Medical, Oral and Biotechnological Sciences, University Gabriele d’Annunzio, 66100 Chieti, Italy
| | - Marco Dolci
- Department of Medical, Oral and Biotechnological Sciences, University Gabriele d’Annunzio, 66100 Chieti, Italy
| | - Elisabetta Ferrara
- Department of Medical, Oral and Biotechnological Sciences, University Gabriele d’Annunzio, 66100 Chieti, Italy
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Ristow O, Hürtgen L, Moratin J, Smielowski M, Freudlsperger C, Engel M, Hoffmann J, Rückschloß T. A critical assessment of the medication-related osteonecrosis of the jaw classification in stage I patients: a retrospective analysis. J Korean Assoc Oral Maxillofac Surg 2021; 47:99-111. [PMID: 33911042 PMCID: PMC8084747 DOI: 10.5125/jkaoms.2021.47.2.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives It is unclear whether the extent of intraoral mucosa defects in patients with medication-related osteonecrosis of the jaw indicates disease severity. Therefore, this study investigated whether mucosal lesions correlate with the true extent of osseous defects in stage I patients. Materials and Methods Retrospectively, all patients with stage I medication-related osteonecrosis of the jaw who underwent surgical treatment between April 2018 and April 2019 were enrolled. Preoperatively, the extent of their mucosal lesions was measured in clinical evaluations, and patients were assigned to either the visible or the probeable bone group. Intraoperatively, the extent of necrosis was measured manually and with fluorescence. Results Fifty-five patients (36 female, 19 male) with 86 lesions (46 visible bone, 40 probeable bone) were enrolled. Intraoperatively, the necrotic lesions were significantly larger (P<0.001) than the preoperative mucosal lesions in both groups. A significant (P<0.05) but very weak (R2<0.2) relationship was noted between the extent of the mucosal lesions and the necrotic bone area. Conclusion Preoperative mucosal defects (visible or probeable) in patients with medication-related osteonecrosis of the jaw do not indicate the extent of bone necrosis or disease severity.
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Affiliation(s)
- Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lena Hürtgen
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julius Moratin
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Smielowski
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Michael Engel
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Rückschloß
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
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Mamilos A, Spörl S, Spanier G, Ettl T, Brochhausen C, Klingelhöffer C. The first quantitative histomorphological analyses of bone vitality and inflammation in surgical specimens of patients with medication-related osteonecrosis of the jaw. J Oral Pathol Med 2020; 50:76-84. [PMID: 32946653 DOI: 10.1111/jop.13112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The purpose of the study was to categorize the vitality and inflammation of resected bone of patients with medication-related osteonecrosis of the jaw (MRONJ) and to correlate the grade of inflammation with the surgical success. METHODS This prospective study includes 44 patients with stage III MRONJ. Necrotic bone was resected in a block fashioned way. After demineralization and staining, histological analyses were performed by measuring the areas of necrotic, vital, and regenerative bone. Areas of chronic and acute inflammation were categorized as non, mild, moderate, and severe and were correlated with surgical success and parameters of inflammation in blood plasma (C-reactive protein and leukocytes). RESULTS An average area of 59.0% was necrotic in the examined specimen. Vital bone was measured with an average area of 40.9%. The stage of chronic inflammation correlated with the amount of vital bone (P < .001) and the success of surgery (P = .002). If acute inflammation was dominant, chronic inflammation areas were found less while necrotic areas were observed more (P < .001). Also, the risk of relapses, wound healing disorders, and the level of C-reactive protein were elevated if acute inflammation was severe or moderate (P = .031). Areas of bone regeneration were seen only in 11.3% of vital bone areas and occurred independently of infection stages. CONCLUSION If possible, surgery should be delayed in patients with signs of severe acute inflammation. Patients may profit from prolonged pre-operative antibiotic therapy to reduce the level of acute inflammation.
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Affiliation(s)
- Andreas Mamilos
- Department of Pathology of the University of Regensburg, Regensburg, Germany
| | - Steffen Spörl
- Department of Cranio-Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Gerrit Spanier
- Department of Cranio-Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Ettl
- Department of Cranio-Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Christoph Klingelhöffer
- Department of Cranio-Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
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Hauer L, Jambura J, Hrusak D, Chalupova M, Posta P, Rusnak S, Vyskocil V. Surgical therapy for medication-related osteonecrosis of the jaw in osteoporotic patients treated with antiresorptive agents. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:100-107. [DOI: 10.5507/bp.2018.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/18/2018] [Indexed: 11/23/2022] Open
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Wang QZ, Liu JY, Pan J. [Progress on medication-related osteonecrosis of the jaw]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2019; 36:568-572. [PMID: 30465354 DOI: 10.7518/hxkq.2018.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe complication of bisphosphonates (BPs) or other targeted agent therapies. MRONJ appears as exposed bone, pus, and swelling in the oral and maxillofacial regions. However, neither surgery nor conservative therapy can eliminate symptoms thoroughly. In addition to BPs, several antiresorptive and antiangiogenic agents, such as denosumab and bevacizumab, as well as targeted agents, such as sunitinib and temsirolimus, can cause osteonecrosis of the jaw according to the literature. This review aims to summarize the research progress on these new drugs.
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Affiliation(s)
- Qi-Zhang Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Ji-Yuan Liu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Jian Pan
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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El-Rabbany M, Lam DK, Shah PS, Azarpazhooh A. Surgical Management of Medication-Related Osteonecrosis of the Jaw Is Associated With Improved Disease Resolution: A Retrospective Cohort Study. J Oral Maxillofac Surg 2019; 77:1816-1822. [PMID: 31054989 DOI: 10.1016/j.joms.2019.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE Optimal management approaches for medication-related osteonecrosis of the jaw (MRONJ) using either surgical or nonsurgical approaches remain inconclusive. Our objective was to compare the effects of surgical versus nonsurgical therapy on the resolution of MRONJ. METHODS We conducted a retrospective review of eligible patients with a diagnosis of MRONJ at Mount Sinai Hospital, Toronto, Ontario, Canada, who either were seen in the outpatient clinic from January 2014 to December 2016 or received major surgical intervention from January 2011 to December 2016. A multivariate logistic regression was conducted to evaluate the effects of surgical therapy on disease resolution. RESULTS A total of 78 patients were included in this study. Of these, 56 (72%) received surgical therapy. Antiresorptive agents were being taken for the treatment of osteoporosis by 46 patients (82%) in the surgical group compared with 20 nonsurgical patients (91%) (P = .28). The median follow-up period was 15.5 months (interquartile range, 8.0 to 34.3 months) in the surgical group compared with 11.0 months (interquartile range, 8.0 to 20.5 months) in the nonsurgical group (P = .75). Disease resolution occurred in 39 surgical patients (70%) compared with 8 nonsurgical patients (36%). Surgical therapy was associated with disease resolution compared with nonsurgical therapy alone, after adjustment for age, duration of antiresorptive or antiangiogenic therapy, whether the antiresorptive or antiangiogenic agents were used for oncologic purposes, and the stage of MRONJ at initial presentation (adjusted odds ratio, 4.33; 95% confidence interval, 1.28 to 14.60). CONCLUSIONS Surgical therapy compared with nonsurgical therapy was associated with disease resolution in patients with MRONJ. High-quality evidence of the superiority of any specific surgical approach in the treatment of MRONJ is needed.
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Affiliation(s)
- Mohamed El-Rabbany
- Resident and PhD Student in Oral and Maxillofacial Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David K Lam
- Professor and Chair, Department of Oral & Maxillofacial Surgery, Stony Brook School of Dental Medicine; Professor, Department of Surgery, Stony Brook School of Medicine; and Surgeon-Scientist, Stony Brook Cancer Center, Stony Brook, NY
| | - Prakesh S Shah
- Professor, Department of Pediatrics, Mount Sinai Hospital; University of Toronto; and Institute of Health, Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Amir Azarpazhooh
- Associate Professor, Dental Public Health and Endodontics, University of Toronto; and Head, Divisions of Endodontics and Research, Department of Dentistry, Mount Sinai Hospital, Toronto, Ontario, Canada.
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Ristow O, Rückschloß T, Müller M, Berger M, Kargus S, Pautke C, Engel M, Hoffmann J, Freudlsperger C. 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. J Craniomaxillofac Surg 2018; 47:491-499. [PMID: 30642734 DOI: 10.1016/j.jcms.2018.12.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/29/2018] [Accepted: 12/21/2018] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Oliver Ristow
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany.
| | - Thomas Rückschloß
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Michael Müller
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Moritz Berger
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Steffen Kargus
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Christoph Pautke
- University of Munich, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. M. Ehrenfeld), Lindwurmstr. 2a, 80337, München, Germany
| | - Michael Engel
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Jürgen Hoffmann
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Christian Freudlsperger
- University of Heidelberg, Department of Oral and Maxillofacial Surgery, (Head of Department: Prof. Dr. Dr. J. Hoffmann), Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
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Oral-Health-Related Quality of Life After Surgical Treatment of Osteonecrosis of the Jaws. J Craniofac Surg 2018; 29:403-408. [PMID: 29135723 DOI: 10.1097/scs.0000000000004087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study is to analyze the clinical outcome and the change in oral-health-related quality of life (QoL) of osteoporotic patients affected by medication-related osteonecrosis of the jaws (MRONJ). Forty-one patients, consecutively treated for a 10-year period, were retrospectively analyzed. All the patients underwent a marginal osseous resective jaw surgery. A clinical 12 months postoperative evaluation has been performed and the complete mucosal healing, the absence of swelling and suppuration, and no signs of disease recurrence were defined like success parameters. Quality-of-life surveys tests like EORTC QQ-C30 and QLQ-HN35 appendices in conjunction with a perceived oral health visual analog scale (VAS) were administered before (time of diagnosis of MRONJ) and after surgery (at least 6 months) in order to record the different oral health status of the treated patients. The majority of MRONJ-diagnosed patients complained symptoms like pain, eating discomfort, and sense problems, with occasional involvement of the social dimension. There was a prevalence of troubles with social eating and social contact.The complete mucosal healing was achieved in 100% of the patients and the administered survey tests reported a significant improvement in all the investigated spheres. Similarly, an increased mean score of perceived oral health VAS was reported.Marginal-resective surgery of the necrotic jaw bone can be an effective treatment of osteoporotic patients affected by localized MRONJ. Quality-of-life parameters are demonstrated to be useful for recording the patient-centered outcome of MRONJ treatment.
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Domah F, Shah N, Domah J, Shah R. Medication-related osteonecrosis of the jaw - a current review. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/ors.12329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- F. Domah
- Oral Surgery; University of Central Lancashire; Preston UK
| | - N. Shah
- Aesthetic Medicine; Queen Mary University of London; London UK
| | - J. Domah
- Trinity College of Dublin; Dublin Ireland
| | - R. Shah
- Prosthodontics; University of Central Lancashire; Preston UK
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Ramaglia L, Guida A, Iorio-Siciliano V, Cuozzo A, Blasi A, Sculean A. Stage-specific therapeutic strategies of medication-related osteonecrosis of the jaws: a systematic review and meta-analysis of the drug suspension protocol. Clin Oral Investig 2018; 22:597-615. [PMID: 29332231 DOI: 10.1007/s00784-017-2325-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/20/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The most debated topic about medication-related osteonecrosis of the jaws (MRONJ) is its therapy, as there are no definitive guidelines. The aims of this systematic review were (a) to outline the best therapeutic approach according to the stage at diagnosis and (b) to perform a meta-analysis to assess whether the drug-holiday protocol may be or not an effective method in the management of MRONJ patients. MATERIALS AND METHODS The systematic review was performed following the PRISMA principles. Results were screened according to inclusion and exclusion criteria regarding staging before/after treatment, follow-up, and information provided by the authors. For statistical analysis, linear variables are reported as means and standard deviations, medians, and inter-quartile range (IQR); normality of data, according to the distribution of complete healing (primary outcome variable), was assessed with the Kolmogorov-Smirnov test. A p value < 0.05 was considered statistically significant for all tests. RESULTS Thirteen studies were selected out of 1480. None of them was case-controlled or randomized. Conservative approach showed good results at early stages, but heterogeneous result at advanced stages (100% stage 0, stage I range 81-97%, stage II range 63.6-100%, stage III 73%). Surgical approach showed heterogeneous results at all stages (stage I range 0-100%, stage II range 52-100%, stage III range 50-100%). Statistical analysis showed a significantly higher prevalence of completely healed sites in patients who followed the drug-holiday protocol. CONCLUSIONS The results suggest that the current stage-specific approach for MRONJ therapy is based on a sound clinical rationale. Conservative treatment appears to yield better outcomes at early stages, while further investigations are needed to elucidate the best protocols for the management of advanced stages. The drug-holiday protocol statistically promotes complete healing after oral surgery procedures but the application should be dictated by the condition of each patient. CLINICAL RELEVANCE At present, early MRONJ stages should be primarily treated by means of a conservative approach while more advanced stages must be carefully evaluated. Individual decisions should be made for every single case even with respect to the drug-holiday protocol.
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Affiliation(s)
- Luca Ramaglia
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Agostino Guida
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Vincenzo Iorio-Siciliano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Alessandro Cuozzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Andrea Blasi
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Anton Sculean
- Department of Periodontology, School of Dental Medicine, University of Bern, Freiburgstrasse 7, 3010, Bern, Switzerland.
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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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El-Rabbany M, Sgro A, Lam DK, Shah PS, Azarpazhooh A. Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis. J Am Dent Assoc 2017; 148:584-594.e2. [PMID: 28527518 DOI: 10.1016/j.adaj.2017.04.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/01/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The effectiveness of management strategies used for the treatment of medication-related osteonecrosis of the jaw (MRONJ) remains poorly understood. The authors evaluated systematically the effectiveness of the various treatment modalities used for MRONJ. TYPES OF STUDIES REVIEWED The authors conducted a comprehensive search of MEDLINE, Embase, the Cochrane Library, and Scopus to identify randomized controlled trials, nonrandomized controlled trials, and prospective cohort studies to evaluate comparatively the effectiveness of management strategies for the treatment of MRONJ. The authors conducted the identification of eligible studies in duplicate and synthesized the extracted data by means of a meta-analysis, when feasible. RESULTS The authors found 13 studies with a medium-to-high risk of bias that met the inclusion criteria of this review. The authors found that, compared with medical treatment of local antimicrobials with or without systemic antimicrobials, the study investigators associated surgical treatment with higher odds of complete resolution of the condition (2 studies; 76 participants; unadjusted odds ratio, 3.55; 95% confidence interval, 1.12 to 11.19). The effectiveness of other therapies, such as bisphosphonate drug holidays, teriparatide, and hyperbaric oxygen, was uncertain. CONCLUSIONS AND PRACTICAL IMPLICATIONS On the basis of the results of an unadjusted analysis, the results of the studies that were deemed to be medium to low quality and to have medium-to-low statistical power suggested that there are higher odds of resolving MRONJ with surgical treatment compared with medical treatment. High-quality research is required for conclusive statements to be made regarding treatment strategies for management of MRONJ.
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13
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Yoneda T, Hagino H, Sugimoto T, Ohta H, Takahashi S, Soen S, Taguchi A, Nagata T, Urade M, Shibahara T, Toyosawa S. Antiresorptive agent-related osteonecrosis of the jaw: Position Paper 2017 of the Japanese Allied Committee on Osteonecrosis of the Jaw. J Bone Miner Metab 2017; 35:6-19. [PMID: 28035494 DOI: 10.1007/s00774-016-0810-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 12/04/2016] [Indexed: 01/12/2023]
Abstract
Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is an intractable, though rare, complication in cancer patients with bone metastases and patients with osteoporosis who are treated with antiresorptive agents, including bisphosphonates and denosumab. Despite the more than 10 years that have passed since the first cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) were reported, our understanding of the epidemiology and pathophysiology of ARONJ remains limited, and data supported by evidence-based medicine are still sparse. However, the diagnosis and staging of ARONJ, identification of risk factors, and development of preventive and therapeutic approaches have advanced significantly over the past decade. The Position Paper 2017 is an updated version of the Position Paper 2010 of the Japanese Allied Committee on Osteonecrosis of the Jaw, which now comprises six Japanese academic societies. The Position Paper 2017 describes a new diagnostic definition for ARONJ, as proposed by the American Association of Oral and Maxillofacial Surgeons (AAOMS), summarizes our current understanding of the pathophysiology of ARONJ based on a literature search, and suggests methods for physicians and dentists/oral surgeons to manage the disease. In addition, the appropriateness of discontinuing antiresorptive medications (drug holiday) before, during, and after invasive dental treatments is discussed extensively. More importantly, the manuscript also proposes, for the first time, the importance of interactive communication and cooperation between physicians and dentists/oral surgeons for the successful treatment of ARONJ. The Position Paper 2017 is intended to serve as a guide for improving the management of ARONJ patients in Japan.
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Affiliation(s)
- Toshiyuki Yoneda
- Division of Hematology and Oncology, Indiana University School of Medicine, Indianapolis, USA.
- The Japanese Society for Bone and Mineral Research, Kyoto, Japan.
| | - Hiroshi Hagino
- School of Health Science, Faculty of Medicine, Tottori University, Tottori, Japan
- The Japanese Society for Bone and Mineral Research, Kyoto, Japan
| | - Toshitsugu Sugimoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Matsue, Japan
- The Japanese Society for Bone and Mineral Research, Kyoto, Japan
| | - Hiroaki Ohta
- Clinical Research Centers for Medicine, International University of Health and Welfare, Ohtawara, Japan
- The Japan Osteoporosis Society, Tokyo, Japan
| | - Shunji Takahashi
- Department of Medical Oncology, The Cancer Institute Hospital Of Japanese Foundation of Cancer Research, Tokyo, Japan
- The Japanese Society for Bone and Mineral Research, Kyoto, Japan
| | - Satoshi Soen
- Department of Orthopaedic Surgery and Rheumatology, Kindai University Nara Hospital, Ikoma, Japan
- The Japan Osteoporosis Society, Tokyo, Japan
| | - Akira Taguchi
- Department of Hard Tissue Research, Graduate School of Oral Medicine, Matsumoto Dental University, Shiojiri, Japan
- The Japanese Society of Oral and Maxillofacial Radiology, Tokyo, Japan
| | - Toshihiko Nagata
- Department of Periodontology and Endodontology, School of Dentistry, Tokushima University, Tokushima, Japan
- The Japanese Society of Periodontology, Tokyo, Japan
| | - Masahiro Urade
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Japan
- The Japanese Society of Oral and Maxillofacial Surgeons, Tokyo, Japan
| | - Takahiko Shibahara
- Department of Oral and Maxillo-Facial Surgery, Tokyo Dental College, Tokyo, Japan
- The Japanese Society of Oral and Maxillofacial Surgeons, Tokyo, Japan
| | - Satoru Toyosawa
- Department of Oral Pathology, Osaka University Graduate School of Dentistry, Suita, Japan
- The Japanese Society of Oral Pathology, Tokyo, Japan
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Zandi M, Dehghan A, Janbaz P, Malekzadeh H, Amini P. The starting point for bisphosphonate-related osteonecrosis of the jaw: Alveolar bone or oral mucosa? A randomized, controlled experimental study. J Craniomaxillofac Surg 2016; 45:157-161. [PMID: 27919595 DOI: 10.1016/j.jcms.2016.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 09/20/2016] [Accepted: 10/25/2016] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Although over a decade has passed since first introduction of BRONJ, the exact pathophysiology of this disease is still unclear. The present experimental study aimed to determine whether the oral mucosa or alveolar bone serves as the starting point for BRONJ development. SUBJECTS AND METHODS Sixty male Wistar rats were randomly assigned into study and control groups (each, n = 30), and received intraperitoneal injection of 0.06 mg/kg zoledronate and saline, respectively, once a week for 12 weeks. At the end of the week 4 of the experiment, all 60 rats underwent unilateral mandibular first molar extraction. A 4 mm defect was made in the contralateral canine alveolar mucosa. At the end of the experiment, rats were sacrificed, and the three areas of interest including extraction, soft tissue defect, and the non-intervention (canine area on the same side of extraction) sites were assessed clinically for presence of bone exposure/fistula, and histologically for status of bone remodeling (only at extraction site) and osteonecrosis. RESULTS In the study group, the frequency of bone exposure/fistula was 80%, 0%, and 0%; and the rate of histological bone necrosis was 83.3%, 20%, and 0%; at the extraction, soft tissue defect, and non-intervention sites, respectively. No clinical and histological sign of bone necrosis was found in the control group. Normal bone remodeling was observed in 0% and 100% of the extraction sockets in the study and control groups, respectively. CONCLUSION Injury to alveolar bone was a stronger trigger for BRONJ development compared to oral mucosal damages.
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Affiliation(s)
- Mohammad Zandi
- Department of Oral and Maxillofacial Surgery, Hamadan University of Medical Sciences, Hamadan, Iran; Dental Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Arash Dehghan
- Department of Pathology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Pejman Janbaz
- Department of Oral and Maxillofacial Surgery, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Hamid Malekzadeh
- Department of Oral and Maxillofacial Surgery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Payam Amini
- Department of Biostatistics, Hamadan University of Medical Sciences, Hamadan, Iran
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15
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Klingelhöffer C, Zeman F, Meier J, Reichert TE, Ettl T. Evaluation of surgical outcome and influencing risk factors in patients with medication-related osteonecrosis of the jaws. J Craniomaxillofac Surg 2016; 44:1694-1699. [PMID: 27591091 DOI: 10.1016/j.jcms.2016.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/29/2016] [Accepted: 08/01/2016] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Surgical treatment of the medication-related osteonecrosis of the jaw (MRONJ) is still challenging. We examined the outcome of the resection of osteonecrotic lesions and the influence of potential risk factors on the operative success. METHODS Seventy six surgical interventions on 40 patients were evaluated in a prospective design with a mean follow-up of 55 weeks. Primary endpoints were: (i) maintenance of the mucosal closure and (ii) decrease of MRONJ stage. Influential variables included preoperative duration, location and diameter of MRONJ, duration and change of antiresorptive therapy, presence of actinomyces species. RESULTS Only in 27.6% of cases long-term maintenance of the mucosal closure was achieved. However, stage II patients decreased to stage I in 81% after surgery (p < 0.01) and stage III patients improved in 83% of cases (OR = 8.08; p = 0.07). Stage I patients profited only in 38% by surgical intervention. MRONJ recurrence after surgery was associated with extended preoperative MRONJ duration (p = 0.015). There was no significance of further influential variables, but MRONJ of the upper jaw seems prognostically more favorable. CONCLUSION Advanced stages of MRONJ benefit from surgical treatment, whereas stage I diseases may also be treated conservatively. An early intervention reduces the risk of recurrence.
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Affiliation(s)
- Christoph Klingelhöffer
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Florian Zeman
- Department of Clinical Studies, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Johannes Meier
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Torsten Eugen Reichert
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Tobias Ettl
- Department of Cranio- and Maxillofacial Surgery, Hospital of the University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
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16
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Free flap reconstruction for patients with bisphosphonate related osteonecrosis of the jaws after mandibulectomy. J Craniomaxillofac Surg 2015; 44:142-7. [PMID: 26752221 DOI: 10.1016/j.jcms.2015.11.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Bisphosphonate related osteonecrosis of the jaws (BRONJ) is a recognised unwanted effect of these drugs which affect bone remodelling. Treatment options range from conservative approaches through local bone debridement to free flap reconstruction following segmental resection. This current study aims to evaluate clinical outcomes after microvascular tissue transfer in BRONJ patients. MATERIAL AND METHODS A total of 212 BRONJ patients were included in this prospective investigation. Those who met defined inclusion criteria and received a surgical intervention were reviewed regularly during a follow-up period of at least 6 months. RESULTS Twenty-five patients (11.8%) received free flap reconstructions. A mean of 2.12 local debridements were performed before microvascular tissue transfer. A mean of 29.25% showed BRONJ recurrence after minimalist surgical intervention, compared to significantly less in patients after resection and free flap reconstruction. The postoperative fistula rate was significantly higher in patients, who received mucoperiosteal flaps. DISCUSSION This study underlines the importance and effectiveness radical resection and free flap reconstruction in the complex and challenging surgical treatment of BRONJ patients in a large patient cohort study. Nevertheless, all patients received radical intervention after failure of minimally invasive treatment. An individualized analysis and planning is necessary to identify appropriate patients for free flap reconstructions.
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