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Penoni DC, Canellas JVS, Silami MANC, Sader F, Pimentel GS, Leão ATT. Osteonecrosis of the jaws in patients under osteoporosis treatment: a nine-year experience report. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:e000612. [PMID: 37252700 PMCID: PMC10665075 DOI: 10.20945/2359-3997000000612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/09/2022] [Indexed: 05/31/2023]
Abstract
Objective This study aimed to report the experience of medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients for nine years, and their associated initiating factors. Materials and methods The numbers of invasive oral procedures (IOP) (tooth extraction, dental implant placement, and periodontal procedures) and removable prostheses performed from January 2012 to January 2021 were obtained from the digital records of a large public dental center. There were an estimated 6,742 procedures performed in patients under osteoporosis treatment. Results Two cases (0.03%) of MRONJ were registered in nine years amongst patients with osteoporosis who had dental treatment at the center. From the 1,568 tooth extractions, one patient (0.06%) developed MRONJ. There was also one case from the 2,139 removable prostheses delivered (0.05%). Conclusion The prevalence of MRONJ associated with osteoporosis treatment was very low. The protocols adopted seem to be adequate for the prevention of this complication. The findings of this study reinforce the rare frequency of MRONJ associated with dental procedures in patients submitted to the pharmacological management of osteoporosis. An integral analysis of systemic risk factors and oral preventive strategies may be considered regularly in the dental treatment of these patients.
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Affiliation(s)
- Daniela Cia Penoni
- Departamento de Saúde, Divisão de Odontologia, Hospital Naval de Brasília, Marinha do Brasil, Brasília, DF, Brasil,
- Departamento de Clínica Odontológica, Divisão de Periodontia, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - João Vitor S Canellas
- INPLASY - International Platform of Registered Systematic Review and Meta-analysis Protocols, Delaware, United States
| | - Marcos Antonio Nunes Costa Silami
- Departamento de Clínica Odontológica, Clínica de Estomatologia e Patologia Oral, Marinha do Brasil, Odontoclínica Central da Marinha, Rio de Janeiro, RJ, Brasil
| | - Flávia Sader
- Departamento de Clínica Odontológica, Divisão de Periodontia, Marinha do Brasil, Odontoclínica Central da Marinha, Rio de Janeiro, RJ, Brasil
| | - Gonçalo Sobreira Pimentel
- Departamento de Clínica Odontológica, Divisão de Implantodontia, Marinha do Brasil, Odontoclínica Central da Marinha, Rio de Janeiro, RJ, Brasil
| | - Anna Thereza Thomé Leão
- Departamento de Clínica Odontológica, Divisão de Periodontia, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Osteonecrosis of the Jaw. Dent J (Basel) 2023; 11:dj11010023. [PMID: 36661560 PMCID: PMC9858620 DOI: 10.3390/dj11010023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Osteonecrosis of the jaw is a condition in which bone cells die due to various causes. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis. Antiresorptive or antiangiogenic drugs cause drug-induced osteonecrosis. The combination of medications, microbial contamination, and local trauma induces this condition. Osteoradionecrosis is a severe radiation therapy side effect that can affect people with head and neck cancer. It is described as an exposed bone area that does not heal for longer than three months after the end of radiation treatment with the absence of any indications of an original tumor, recurrence, or metastasis. Trauma (tooth extraction), tumor site, radiation dose that the patient receives, the area of the bone which is irradiated, oral hygiene, and other factors are risk factors for the development of osteonecrosis. Less frequently, osteonecrosis can also be induced by non-traumatic and traumatic causes. Non-traumatic osteonecrosis is brought on by infections, acquired and congenital disorders, as well as the impact of chemicals. Traumatic osteonecrosis is brought on by thermal, mechanical, or chemical damage. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient's quality of life, and surgical, which involves debridement of the necrotic bone.
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Nashi M, Hirai T, Iwamoto T, Takenobu T. Clinical risk factors for severity and prognosis of antiresorptive agent-related osteonecrosis of the jaw: a retrospective observational study. J Bone Miner Metab 2022; 40:1014-1020. [PMID: 36166107 DOI: 10.1007/s00774-022-01367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The incidence of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is rare, and its management has not yet been established. This study aimed to investigate the predictors for advanced stage and healing of ARONJ to establish an appropriate treatment strategy. MATERIALS AND METHODS We retrospectively analyzed patients diagnosed with ARONJ at Kobe City Medical Center General Hospital between April 2014 and March 2020. Outcomes were defined as stage ≥ 2 ARONJ (primary) and healing of ARONJ (secondary). Multivariate logistic regression analysis was used to detect factors associated with the outcomes, and odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS This study included 143 patients (stage ≥ 2 ARONJ, 51%; healing of ARONJ, 60%). Multivariate logistic regression analysis revealed that advanced age (per year) (OR 1.037; 95% CI 1.003-1.072; p = 0.028) and serum albumin (per g/dL) (OR 0.430; 95% CI 0.213-0.869; p = 0.018) were significantly associated with stage ≥ 2 ARONJ. Furthermore, multivariate logistic regression analysis revealed that cancer (yes) (OR 0.099; 95% CI 0.029-0.339; p < 0.001), conservative surgical treatment (yes) (OR 15.42; 95% CI 5.657-42.0; p < 0.001), C-reactive protein (per mg/dL) (OR 0.599; 95% CI 0.415-0.864; p < 0.001), and vitamin D analog (yes) (OR 0.167; 95% CI 0.034-0.827; p = 0.028) were factors associated with healing. CONCLUSION Our findings suggest that age and hypoalbuminemia are associated with the severity of ARONJ, and cancer, high inflammation, and vitamin D analog may impair healing. In contrast, conservative surgical treatment can overcome the poor treatment outcomes associated with ARONJ.
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Affiliation(s)
- Masanori Nashi
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Toshinori Hirai
- Department of Pharmacy, Faculty of Medicine, Mie University Hospital, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Faculty of Medicine, Mie University Hospital, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Anastasilakis AD, Pepe J, Napoli N, Palermo A, Magopoulos C, Khan AA, Zillikens MC, Body JJ. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab 2022; 107:1441-1460. [PMID: 34922381 PMCID: PMC9016445 DOI: 10.1210/clinem/dgab888] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ). OBJECTIVE We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them. METHODS A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM. RESULTS The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. CONCLUSION The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.
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Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 General Military Hospital, 564 29 N Efkarpia Thessaloniki, Greece
- Correspondence: Athanasios D. Anastasilakis, PhD, Department of Endocrinology, 424 General Military Hospital, Ring Rd, 564 29 N Efkarpia, Thessaloniki, Greece.
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Christos Magopoulos
- Department of Oral and Maxillofacial Surgery, 424 General Military Hospital, 56429 Thessaloniki, Greece
| | - Aliya A Khan
- Division of Endocrinology and Metabolism and Geriatrics, McMaster University, L8N3Z5 Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, 2040 Rotterdam, the Netherlands
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, 1050 Brussels, Belgium
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Vitamin D and Its Role in Oral Diseases Development. Scoping Review. Dent J (Basel) 2021; 9:dj9110129. [PMID: 34821593 PMCID: PMC8618634 DOI: 10.3390/dj9110129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 12/27/2022] Open
Abstract
Vitamin D is a fat-soluble secosteroid that plays a significant role in the whole body, including the maxillofacial region. The discovery of its receptors in many cells and organs made it possible to reveal the participation of vitamin D not only in the regulation of calcium phosphate metabolism, but also in immune processes, in providing anti-inflammatory and antimicrobial effects, slowing down cell proliferation and stimulating differentiation. In this literature review, we demonstrate the association between low vitamin D levels and the development of recurrent aphthous stomatitis, the course and response to treatment of squamous cell carcinoma of the oral cavity, the severity of periodontal diseases, and the processes of osseointegration and bone remodeling during dental implantation and guided tissue regeneration. The aim of our article was to demonstate a possible connection between vitamin D level and the oral diseases that can be presented at an oral surgery appointment, which will help clinicians to reduce the risk of early dental implant failure, ensure favorable outcomes of augmentative operations, as well as decrease the destructive effects of severe periodontitis and other conditions throug knowledge and timely lab tests and endocrinologist prescriptions.
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Schubert L, Russmueller G, Lagler H, Tobudic S, Heindel E, Kundi M, Steininger C. Bone turnover markers can predict healing time in medication-related osteonecrosis of the jaw. Support Care Cancer 2021; 29:7895-7902. [PMID: 34189608 PMCID: PMC8550071 DOI: 10.1007/s00520-021-06361-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
Objectives Medication-related osteonecrosis of the jaw (MRONJ) is a severe and difficult-to-treat adverse event of bone-modifying agents. Therefore predictive strategies determining patients at risk for a prolonged healing duration are needed to optimize treatment. Thus, the present study evaluates whether or not bone turnover markers can be used to predict the healing duration in MRONJ patients. Materials and methods The present study is a retrospective data analysis of patients suffering from MRONJ and positive histology for Actinomyces spp., who were identified at the General Hospital Vienna from 2014 to 2018. During the first visit, the patients’ demographics and levels of bone formation parameters were compiled. Healing times were analysed by Cox regression in dependence on these factors. Results A total of 52 patients were identified who fulfilled the inclusion criteria. The indication for bone-modifying agents was breast cancer (n = 21), prostate cancer (n = 14), multiple myeloma (n = 6) and other malignant diseases (n = 11). In 43 (82.7%) of our patients, we were able to document complete mucosal healing. Furthermore, patients who responded faster to therapy showed higher levels of C-telopeptide (P < 0.05), osteocalcin (P < 0.05) and bone-specific alkaline phosphatase (P < 0.05), but lower levels of 1.25-dihydroxyvitamin D (P < 0.05) than slower responding patients. No correlation was found regarding parathyroid hormone or calcitonin levels. Interestingly, patients who had a slower response were less likely to report dental procedures, but more likely to report a history of chemotherapy. Conclusion CTX and osteocalcin levels may be used for predicting healing duration for MRONJ.
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Affiliation(s)
- Lorenz Schubert
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Guenter Russmueller
- Department of Oral and Maxillofacial Surgery, Medical University Vienna, Vienna, Austria
| | - Heimo Lagler
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Selma Tobudic
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Elisabeth Heindel
- Department of Oral and Maxillofacial Surgery, Medical University Vienna, Vienna, Austria
| | - Michael Kundi
- Center for Public Health, Medical University Vienna, Vienna, Austria
| | - Christoph Steininger
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Bilani N, Elson L, Szuchan C, Elimimian E, Saleh M, Nahleh Z. Newly-identified Pathways Relating Vitamin D to Carcinogenesis: A Review. In Vivo 2021; 35:1345-1354. [PMID: 33910812 DOI: 10.21873/invivo.12387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The epidemiological relationship between vitamin D levels and cancer has been thoroughly investigated. Published data from large studies appear to corroborate a significant relationship between higher serum vitamin D concentrations and improved survival. Mechanistic reviews on commonly-studied cancers - including breast cancer, colon cancer and melanoma - focus predominantly on data from older studies. In outlining avenues for future research, we believe there is utility in summarizing novel findings introduced to the literature. MATERIALS AND METHODS In this narrative review, we used MEDLINE, PUBMED and Cochrane databases to identify mechanistic studies published from January 1, 2015 onwards exploring this topic. RESULTS Twenty-five mechanistic studies were included in this review. It was found that vitamin D plays a critical role in both direct (i.e. tumor gene expression, proliferation, invasiveness, sensitivity to chemotherapy etc.) and indirect (i.e. effects on the tumor microenvironment and immunomodulation) tumor suppression mechanisms. CONCLUSION These newly-identified pathways warrant further research, with the hopes that we may understand how and when vitamin D supplementation can be integrated into precision medicine therapeutics for cancers of the breast, colon and skin. Cancer care providers should consider recommendations to screen for vitamin D deficiency in this population.
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Affiliation(s)
- Nadeem Bilani
- Department of Hematology-Oncology, Cleveland Clinic Florida, Weston, FL, U.S.A.;
| | - Leah Elson
- Department of Hematology-Oncology, Cleveland Clinic Florida, Weston, FL, U.S.A
| | - Charles Szuchan
- Department of Hematology-Oncology, Cleveland Clinic Florida, Weston, FL, U.S.A
| | - Elizabeth Elimimian
- Department of Hematology-Oncology, Cleveland Clinic Florida, Weston, FL, U.S.A
| | | | - Zeina Nahleh
- Department of Hematology-Oncology, Cleveland Clinic Florida, Weston, FL, U.S.A
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Michalak F, Hnitecka S, Dominiak M, Grzech-Leśniak K. Schemes for Drug-Induced Treatment of Osteonecrosis of Jaws with Particular Emphasis on the Influence of Vitamin D on Therapeutic Effects. Pharmaceutics 2021; 13:pharmaceutics13030354. [PMID: 33800247 PMCID: PMC7999491 DOI: 10.3390/pharmaceutics13030354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022] Open
Abstract
Drugs that inhibit bone resorption are prescribed most often by orthopedists, hematologists, or oncologists. Dental practice rarely draws attention to their importance and the effects they carry. The problem concerns mainly older people owing to oncological problems or postmenopausal consequences, but everyone can be at risk. Carefully conducted interviews and analysis of history and disease should always be performed before any action is taken by patients taking this type of medicine. Further action should consider possible complications and, above all, the risk of their occurrence. In this article, the most important issues related to the treatment of drug-induced osteonecrosis of the jaws (ONJ) are raised, including medication-related osteonecrosis of the jaw (MRONJ); conservative treatment, including the use of laser; and the impact of vitamin D supplementation on the overall treatment, prognosis, and prevention before complication, which is osteonecrosis of the jaw in the course of treatment with bisphosphonates and other drugs predisposing to MRONJ, such as denosumab and angiogenesis inhibitors. The degree of osteonecrosis is also critical, as it is possible to avoid surgical procedures for only conservative methods that sometimes bring good results. Surgical treatment of advanced stages is complicated and carries a high risk of error and complications. MRONJ is a disease that is easy to avoid, but it is difficult to treat and treatment sometimes leads only to a partial remission of the disease, not a complete cure.
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Affiliation(s)
- Filip Michalak
- Oral Surgery Department, Wroclaw Medical University, 50-367 Wroclaw, Poland; (F.M.); (M.D.)
| | - Sylwia Hnitecka
- Maxillofacial Surgery Department, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Marzena Dominiak
- Oral Surgery Department, Wroclaw Medical University, 50-367 Wroclaw, Poland; (F.M.); (M.D.)
| | - Kinga Grzech-Leśniak
- Oral Surgery Department, Wroclaw Medical University, 50-367 Wroclaw, Poland; (F.M.); (M.D.)
- Department of Periodontics, School of Dentistry, Virginia Commonwealth University (VCU), Richmond, VA 23298, USA
- Correspondence:
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Nakai Y, Kanaki T, Yamamoto A, Tanaka R, Yamamoto Y, Nagahara A, Nakayama M, Kakimoto KI, Ishibashi M, Nishimura K. Antiresorptive agent-related osteonecrosis of the jaw in prostate cancer patients with bone metastasis treated with bone-modifying agents. J Bone Miner Metab 2021; 39:295-301. [PMID: 32886176 DOI: 10.1007/s00774-020-01151-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The incidence rate and risk factors of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) in prostate cancer patients with bone metastasis are not clear. MATERIALS AND METHODS We retrospectively reviewed patients' records of prostate cancer patients with bone metastasis who were treated with zoledronic acid or denosumab between 1/Dec/2008 and 31/Mar/2019. ARONJ-free survival rate was analyzed with Kaplan-Meier analysis, and risk factors for ARONJ were analyzed with Cox proportional hazard model. RESULTS We identified 124 and 67 patients treated with zoledronic acid and denosumab, respectively. Seventy-six patients were hormone sensitive, and 115 patients were castration resistant when they started bone-modifying agents (BMA). Twenty-eight patients developed ARONJ during the observation period (median: 23 months, range 1-130 months). Their number of doses of BMA ranged 3-69 (median: 21.5). The 2-year ARONJ-free survival rate was 91.1%, and the 5-year ARONJ-free survival rate was 72.5%. There was no significant difference in the incidence rate of ARONJ between zoledronic acid and denosumab. However, multivariate analysis revealed that use of denosumab (hazard ratio [HR] 3.67, 95% confidence interval [CI] 1.01-13.31; p = 0.0484), serum calcium < 9.2 mg/dL (HR 3.16, 95% CI 1.10-9.13; p = 0.033)), and concomitant or prior use of chemotherapeutic agents (HR 4.71, 95% CI 1.51-14.71; p = 0.0076) were independent risk factors for the development of ARONJ. CONCLUSION Almost one-quarter of patients had a risk of developing ARONJ within 5 years after starting BMA. Low serum calcium, use of chemotherapeutic agents, and use of denosumab might contribute to the development of ARONJ.
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Affiliation(s)
- Yasutomo Nakai
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Tomohiro Kanaki
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Akinaru Yamamoto
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Ryo Tanaka
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Yoshiyuki Yamamoto
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Akira Nagahara
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Masashi Nakayama
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Ken-Ichi Kakimoto
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Miki Ishibashi
- Department of Dentistry, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuo Nishimura
- Department of Urology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan.
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Dalle Carbonare L, Mottes M, Valenti MT. Medication-Related Osteonecrosis of the Jaw (MRONJ): Are Antiresorptive Drugs the Main Culprits or Only Accomplices? The Triggering Role of Vitamin D Deficiency. Nutrients 2021; 13:561. [PMID: 33567797 PMCID: PMC7915474 DOI: 10.3390/nu13020561] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 01/20/2023] Open
Abstract
Osteonecrosis of the jaw (ONJ) is a severe clinical condition characterized mostly but not exclusively by an area of exposed bone in the mandible and/or maxilla that typically does not heal over a period of 6-8 weeks. The diagnosis is first of all clinical, but an imaging feedback such as Magnetic Resonance is essential to confirm clinical suspicions. In the last few decades, medication-related osteonecrosis of the jaw (MRONJ) has been widely discussed. From the first case reported in 2003, many case series and reviews have appeared in the scientific literature. Almost all papers concerning this topic conclude that bisphosphonates (BPs) can induce this severe clinical condition, particularly in cancer patients. Nevertheless, the exact mechanism by which amino-BPs would be responsible for ONJ is still debatable. Recent findings suggest a possible alternative explanation for BPs role in this pattern. In the present work we discuss how a condition of osteomalacia and low vitamin D levels might be determinant factors.
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Affiliation(s)
- Luca Dalle Carbonare
- Department of Medicine, Section of Internal Medicine, University of Verona, 37134 Verona, Italy;
| | - Monica Mottes
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Biology and Genetics, University of Verona, 37134 Verona, Italy;
| | - Maria Teresa Valenti
- Department of Medicine, Section of Internal Medicine, University of Verona, 37134 Verona, Italy;
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Lentzen MP, Buller J, Riekert M, Grandoch A, Kreppel M, Zöller JE, Zirk M. Bisphosphonate application and volumetric effects on MRONJ lesions. J Craniomaxillofac Surg 2021; 49:501-507. [PMID: 33853745 DOI: 10.1016/j.jcms.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/27/2020] [Accepted: 01/31/2021] [Indexed: 01/22/2023] Open
Abstract
The purpose of this investigation was to analyze the volume of medication-related osteonecrosis of the jaw (MRONJ) lesions by semi-automatic segmentation of cone-beam computed tomography images, and correlate the results with the underlying diseases and applied medication. MRONJ lesions detected in cone-beam computed tomography images were assessed. The open-source software ITK-Snap enabled volumetric measurements of MRONJ lesions based on semi-automatic segmentation. Results were analyzed according to necrosis volume, localization, and gender. In addition, the underlying disease and the type of application of antiresorptive medication were investigated. Cone-beam computed tomography images of 66 patients were studied. 34 male and 32 female patients were included, with ages ranging from 50 to 93 years at the time of diagnosis. The mean volume was 993.24 ± 620.94 mm3: 484.73 ± 230.97 mm3 for the upper jaw and 1084.04 ± 625.74 mm3 for the lower jaw. The results indicated statistically significant differences between lesions of the upper and lower jaw, regardless of gender (p = 0.003). The analysis of differences between males and females did not show any significant results (p = 0.464), although males presented slightly larger lesions than females. With regard to the underlying disease, patients with osteoporosis presented larger volumes, whereas patients with malignant tumors presented smaller volumes. Nevertheless, no statistically significant differences according to the underlying disease (p = 0.313) were detected. However, patients with intravenous (iv) application showed statistically significantly larger lesions than patients who underwent oral or subcutaneous (s.c.) applications (p = 0.004). It seems that the osteonecrosis volume correlates with the applied antiresorptive agents. Larger MRONJ lesions should be expected in patients who receive intravenous antiresorptive therapy.
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Affiliation(s)
- Max-Philipp Lentzen
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany.
| | - Johannes Buller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
| | - Maximilian Riekert
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
| | - Andrea Grandoch
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
| | - Matthias Kreppel
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
| | - Joachim E Zöller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
| | - Matthias Zirk
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital Cologne and Faculty of Medicine, University of Cologne, Germany
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Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients 2020; 12:E1471. [PMID: 32438644 PMCID: PMC7285165 DOI: 10.3390/nu12051471] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022] Open
Abstract
Vitamin D (VD) levels have been gaining growing attention in Oral Health. During growth and adulthood, VD deficiency (VDD) is associated with a wide variety of oral health disorders, and impaired VD synthesis may expedite some of these conditions. In children, severe VDD can induce defective tooth mineralization, resulting in dentin and enamel defects. As a consequence, these defects may increase the risk of the onset and progression of dental caries. Further, VDD has been associated with higher prevalence of periodontitis and gingival inflammation, and several recent preclinical and clinical studies have unveiled potential pathways through which Vitamin D may interact with the periodontium. VDD correction through supplementation may contribute to a successful treatment of periodontitis; however, alveolar bone regeneration procedures performed in baseline VDD patients seem more prone to failure. Vitamin D may also be linked with some oral pathology entities such as certain oral cancers and events of osteonecrosis of the jaw. This review aims to provide comprehensive evidence of how VD levels should be considered to promote good oral health, and to summarize how VDD may hamper oral development and its role in certain oral conditions.
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Affiliation(s)
- João Botelho
- Periodontology Department, Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
| | - Vanessa Machado
- Periodontology Department, Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
- Orthodontics Department, CRU, CiiEM, Egas Moniz–Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal
| | - Luís Proença
- Quantitative Methods for Health Research Unit (MQIS), CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
| | - Ana Sintra Delgado
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
- Orthodontics Department, CRU, CiiEM, Egas Moniz–Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal
| | - José João Mendes
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
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Zirk M, Buller J, Zöller JE, Heneweer C, Kübler N, Lentzen MP. Volumetric analysis of MRONJ lesions by semiautomatic segmentation of CBCT images. Oral Maxillofac Surg 2019; 23:465-472. [PMID: 31673817 DOI: 10.1007/s10006-019-00805-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/11/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate potential differences in volumes of areas of osteolysis caused by medication-related osteonecrosis of the jaw (MRONJ) between the upper and lower jaw. We aim to analyze the clinical relevance of volumetric measurement of osteolytic lesions for surgical planning of MRONJ patients. METHODS Sixty-seven patients who were clinically and histopathologically diagnosed with MRONJ were retrospectively included in this study. Cone beam computed tomography (CBCT) images were evaluated according to localization, affected anatomical structures, and volumetric measurement of osteolytic lesions caused by MRONJ in appliance of CBCT datasets by using ITK-SNAP. RESULTS The most frequently affected localization is the mandible, whereas female patients show significantly more often lesions of the maxilla. The cortical bone was predominantly affected. Furthermore, the affection of teeth, sinus floor, inferior alveolar nerve canal, or even a pathological fracture of the mandible are infrequently existing. The volumetric measurements revealed a statistically significant greater absolute osteolysis volume in males. CONCLUSIONS Image analysis and volumetric measurements of osteolytic lesions of MRONJ patients is a helpful tool to further understand the clinical appearance and identify compromised anatomic landmarks. Volumetric analysis aids in pre-surgical planning and visualizes the individual extent of the disease for each patient.
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Affiliation(s)
- Matthias Zirk
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany.
| | - Johannes Buller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Joachim E Zöller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Carola Heneweer
- Institute of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Norbert Kübler
- Department for Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Max-Philipp Lentzen
- Department for Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
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Heim N, Götz W, Kramer FJ, Faron A. Antiresorptive drug-related changes of the mandibular bone densitiy in medication-related osteonecrosis of the jaw patients. Dentomaxillofac Radiol 2019; 48:20190132. [PMID: 31530019 DOI: 10.1259/dmfr.20190132] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Medication-related osteonecrosis of the jaw (MRONJ) is a well known side-effect of anti-resorptive drugs. Changes in bone density might potentially constitute the development of ONJ. This study aimed to investigate, to which degree bisphosphonates (bp) and denosumab (db) induce changes in bone density that can be determined from routine diagnostic CT. METHODS CT scans of 101 patients were investigated. MRONJ was present in 61 patients (n = 26: db-treated; n = 35 bp-treated). 40 patients were included as a reference group. Bone density was measured at two distinct locations in the mandible (M1: anterior of the mental foramen; M2: retromolar), each on the contralateral side to the necrosis. RESULTS The bone density values measured at both locations were found to be significantly higher in the bp-group compared to the db-group (p = 0.027) and to the reference-group (p = 0.016). Almost no difference (p = 0.84) in bone density value was found between the db- and reference-groups.Investigating the effect of duration of treatment, none of the measured values showed significant differences in both locations of db- and bp-group. CONCLUSION The findings from this study suggest that that bisphosphonates change the microarchitecture of the alveolar bone by being embedded in the mandible, which may subsequently lead to a bp-specific corticalization, and a decrease in vascularization of the lower jaw. This process may be distinctive for bp-treatment and seems to induce the congestion of cancellous bone rather rapidly after the first administrations. This effect could not be determined in denosumab-treated patients.
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Affiliation(s)
- Nils Heim
- Department for Oral & Cranio-Maxillo and Facial Plastic Surgery, University Clinic Bonn Germany Sigmund-Freud-Str. 25 Haus 11, 2. Obergeschoss 53127 Bonn, Bonn, Germany
| | - Werner Götz
- University of Bonn, Department of Orthodontics, Dental Hospital of the University of Bonn, Head of the Oral Biology Laboratory, Bonn, Germany
| | - Franz-Josef Kramer
- Department for Oral & Cranio-Maxillo and Facial Plastic Surgery, University Clinic Bonn Germany Sigmund-Freud-Str. 25 Haus 11, 2. Obergeschoss 53127 Bonn, Bonn, Germany
| | - Anton Faron
- University of Bonn, Department for Radiology, Bonn, Germany
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Prevalence and risk factors of medication-related osteonecrosis of the jaw in osteoporotic and breast cancer patients: a cross-sectional study. Support Care Cancer 2019; 28:2265-2271. [PMID: 31468192 DOI: 10.1007/s00520-019-05044-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Medication-related osteonecrosis of the jaw (MRONJ) has been reported as a side effect of bisphosphonate (BP). The aim of this study was to identify the prevalence of MRONJ in women taking BP for osteoporosis and for metastatic breast cancer and correlate it with risk factors and biochemical markers of bone metabolism. METHODS Patients taking oral or intravenous BP with osteoporosis (G1; n = 153; median 72.8 years) and with metastatic breast cancer (G2; n = 134; median 58.2 years) had their hospital charts reviewed, were submitted to dental inspection, and answered a health questionnaire. Fasting blood samples were randomly collected from both groups to measure osteocalcin, carboxy-terminal cross-linking telopeptide of type I collagen, intact parathyroid hormone and procollagen type 1 amino-terminal propeptide (P1NP), 25 hydroxyvitamin D (25OHD), creatinine, and total calcium. RESULTS G1 was older (p = 0.001) and had more cases of diabetes (p = 0.043). P1NP was higher (p = 0.022) and 25OHD lower (p = 0.004) in G2 compared with G1. MRONJ was not found in the G1, whereas 4 cases (3%) were detected in G2. Positive risk factors for MRONJ were number of BP doses and number of visits to the dentist and dental extractions. The biochemical parameters, however, could not identify those who developed MRONJ. CONCLUSIONS The prevalence of MRONJ was 3% in women with metastatic breast cancer receiving BP. No cases were identified in women receiving oral BP chronically for osteoporosis. P1NP was higher in women with metastatic breast cancer, even during treatment with antiresorptives, but could not differentiate those with MRONJ.
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Bedogni A, Bettini G, Bedogni G, Basso D, Gatti D, Valisena S, Brunello A, Sorio M, Berno T, Giannini S, Navaglia F, Plebani M, Nocini PF, Blandamura S, Saia G, Bertoldo F. Is vitamin D deficiency a risk factor for osteonecrosis of the jaw in patients with cancer? A matched case-control study. J Craniomaxillofac Surg 2019; 47:1203-1208. [PMID: 30929994 DOI: 10.1016/j.jcms.2019.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/11/2019] [Accepted: 03/06/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE A previous case-control histomorphometric study showed higher odds of osteomalacia in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ). Vitamin D deficiency causes osteomalacia and may therefore be involved in the pathogenesis of BRONJ. The present case-control study aimed at testing such hypothesis. MATERIALS AND METHODS BRONJ+ and BRONJ- patients treated with bisphosphonates were matched by sex (same) and age (within 5 years). Serum 25-hydroxy-vitamin D (25-OH-D), parathyroid hormone, bone alkaline phosphatase, total procollagen type 1 amino-terminal propeptide, carboxy-terminal collagen crosslinks, Dickkopf WNT signaling pathway inhibitor 1 and sclerostin were measured. RESULTS The main outcome was vitamin D deficiency defined as 25-OH-D < 50 nmol/l. A total of 51 BRONJ+ and 73 BRONJ- patients were studied. The frequency (95% CI) of vitamin D deficiency was 59% (45%-72%) in BRONJ+ and 62% (48%-75%) in BRONJ- patients. This amounts to a difference of -3% (-22%-16%, p = 0.77) for BRONJ+ patients. Serum 25-hydroxy-vitamin D and parathyroid hormone were similar in BRONJ+ and BRONJ- patients. Among the bone metabolism markers, only sclerostin differed between the two groups, being higher in BRONJ+ patients. CONCLUSION The present matched case-control study suggests that vitamin D deficiency is not a risk factor for BRONJ.
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Affiliation(s)
- Alberto Bedogni
- Unit of Maxillofacial Surgery, Department of Neuroscience-DNS, University of Padua, Padua, Italy.
| | - Giordana Bettini
- Unit of Maxillofacial Surgery, Department of Neuroscience-DNS, University of Padua, Padua, Italy
| | - Giorgio Bedogni
- Clinical Epidemiology Unit, Liver Research Center, Basovizza, Trieste, Italy
| | - Daniela Basso
- Unit of Laboratory Medicine, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Davide Gatti
- Unit of Rheumatology, Department of Medicine, University of Verona, Verona, Italy
| | - Silvia Valisena
- Service of Traumatology, Orthopedics and Hand Surgery, Regional Hospital of Bellinzona, Switzerland
| | | | - Marco Sorio
- Unit of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Tamara Berno
- Hematology and Clinical Immunology Branch, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Sandro Giannini
- Unit of Internal Medicine, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Filippo Navaglia
- Unit of Laboratory Medicine, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Mario Plebani
- Unit of Laboratory Medicine, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Pier Francesco Nocini
- Unit of Oral and Maxillofacial Surgery, Department of Surgery, University of Verona, Verona, Italy
| | | | - Giorgia Saia
- Unit of Maxillofacial Surgery, Department of Neuroscience-DNS, University of Padua, Padua, Italy
| | - Francesco Bertoldo
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
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Zirk M, Wenzel C, Buller J, Zöller JE, Zinser M, Peters F. Microbial diversity in infections of patients with medication-related osteonecrosis of the jaw. Clin Oral Investig 2018; 23:2143-2151. [PMID: 30276516 DOI: 10.1007/s00784-018-2655-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 09/20/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES A central role of infections in the treatment of MRONJ patients is widely accepted. An investigation of the MRONJ lesions' biofilms as potential pathogens seems logical. MATERIALS AND METHODS We investigated the clinical data of our MRONJ patients who received surgery in advanced stage of the disease. Special attention was granted to the local colonizers harvested from osseous MRONJ specimens and submucosal putrid infections. RESULTS Eleven out of 71 patients presented a spontaneous onset of the disease and for 60 out of 71 patients a trigger was detected. Breast cancer (29.6%) and prostate cancer (22.5%) were the most frequent underlying disease for prescription of an antiresorptive therapy, mostly zoledronate. Submucosal soft tissue biofilms significantly differed from biofilms harvested from the MRONJ lesions bottom, yet the most frequent bacteria were equally present in both groups: Streptococcus species (spp.), Prevotella spp., Actinomyces spp., Veillonella spp., and Parvimonas micra. The cephalosporins, cefuroxime and cefotaxime, and ß-lactam antibiotics with ß-lactamase inhibitor revealed the greatest susceptibility for the detected bacteria. CONCLUSION The bacteria from the submucosal areas and the bottom of the infected bone presented comparable susceptibility to the common antibiotics regimes. Streptococcus spp., Prevotella spp., and Veillonella spp. present a high abundance in MRONJ lesions beside Actinomyces spp. The MRONJ lesions bottom is in many cases not infected by Actinomyces spp. CLINICAL RELEVANCE The removal of the necrotic bone reduces the variety of bacteria found in MRONJ lesions, in particular at the bottom of the lesion.
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Affiliation(s)
- Matthias Zirk
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse, 62 50931, Cologne, Germany.
| | - Charlotte Wenzel
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse, 62 50931, Cologne, Germany
| | - Johannes Buller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse, 62 50931, Cologne, Germany
| | - Joachim E Zöller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse, 62 50931, Cologne, Germany
| | - Max Zinser
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse, 62 50931, Cologne, Germany
| | - Franziska Peters
- Department of Dermatology, University of Cologne, Cologne, Germany.,Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
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