1
|
Hadaya D, Soundia A, Bezouglaia O, Pirih F, Aghaloo TL, Tetradis S. The Incidence and Severity of Medication Related Osteonecrosis of the Jaws is Similar in Male and Female Mice. J Oral Maxillofac Surg 2024:S0278-2391(24)00391-4. [PMID: 38909629 DOI: 10.1016/j.joms.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 06/01/2024] [Accepted: 06/02/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Medication related osteonecrosis of the jaws (MRONJ), a rare side-effect of antiresorptive medications, is described as exposed bone in the oral cavity that lasts for at least 8 weeks. Most studies report a female predilection for MRONJ; these findings could be due to the increased use of antiresorptives in females, or due to inherent differences between male versus female patients. PURPOSE The purpose of this study was to measure and compare the incidence and severity of osteonecrosis of the jaws (ONJ) between male and female mice. STUDY DESIGN, SETTING, SAMPLE We designed a randomized in-vivo animal study utilizing male and female mice treated with zoledronic acid (ZA). Experimental periodontitis was induced in 24 male and 24 female mice using a silk ligature following administration of saline or a potent bisphosphonate. After 8 weeks, animals were evaluated radiographically and histologically. INDEPENDENT VARIABLE The independent variables were sex (male vs female) and treatment group (ZA vs saline control). Treatment was randomly assigned with balanced distribution between male and female animals. MAIN OUTCOME VARIABLE The main outcome variable was ONJ status coded as present or absent. ONJ was defined as present if there was histologic contact between the ligature and the alveolar bone. Secondary outcomes of interest were radiographic and histologic parameters. ANALYSIS Statistical differences were analyzed using a two-way analysis of variance with Tukey's post hoc test using a P value of 0.05 for significance. RESULTS The final sample was composed of 24 vehicle treated and 24 ZA treated animals. In vehicle treated animals, 8% of female and 8% of male animals developed ONJ. In ZA treated animals, 83% of female and 92% of male animals developed ONJ. Sex was not associated with the risk (measured as incidence of disease) for developing ONJ or in the radiographic or histologic parameters that were assessed (P values >.1). CONCLUSIONS Sex does not appear to affect the incidence of MRONJ or the severity of the disease as assessed by the radiographic and histologic parameters.
Collapse
Affiliation(s)
- Danny Hadaya
- Resident, Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA
| | | | - Olga Bezouglaia
- Staff Research Associate, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA
| | - Flavia Pirih
- Professor, Tarrson Family Endowed Chair in Periodontics, Chair of Division of Regenerative and Reconstructive Sciences, UCLA School of Dentistry, Los Angeles, CA
| | - Tara L Aghaloo
- Professor, Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA
| | - Sotirios Tetradis
- Professor, Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, & Senior Associate Dean, UCLA School of Dentistry, Los Angeles, CA.
| |
Collapse
|
2
|
Ward J, Singh A, White C, Riedel E, Lewis R, Yom SK, Halpern J, Randazzo JD, Kronstadt KL, Huryn JM, Estilo CL. Determinants of outcome in cancer patients with medication-related osteonecrosis of the jaw: A 19-year retrospective study. ORAL ONCOLOGY REPORTS 2024; 10:100488. [PMID: 38957376 PMCID: PMC11218890 DOI: 10.1016/j.oor.2024.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Jenna Ward
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Annu Singh
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Elyn Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Roxanne Lewis
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - SaeHee K. Yom
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Jerry Halpern
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Joseph D. Randazzo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Kenneth L. Kronstadt
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Joseph M. Huryn
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Cherry L. Estilo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| |
Collapse
|
3
|
Vitale M, Corrêa MG, Ervolino E, Cirano FR, Ribeiro FV, Monteiro MF, Casati MZ, Pimentel SP. Resveratrol for preventing medication-related osteonecrosis of the jaws in rats. Oral Dis 2024; 30:1462-1474. [PMID: 36807967 DOI: 10.1111/odi.14544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/31/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
This study evaluated the effect of resveratrol (RES) on the prevention of medication-related osteonecrosis of the jaws (MRONJ) in ovariectomized (OVX) rats treated with zoledronate (ZOL). Fifty rats were distributed in five groups: SHAM (n = 10): non-ovariectomy + placebo; OVX (n = 10):ovariectomy + placebo; OVX + RES (n = 10):ovariectomy + resveratrol; OVX + ZOL (n = 10):ovariectomy + placebo + zoledronate; and OVX + RES + ZOL (n = 10):ovariectomy + resveratrol + zoledronate. The mandibles left sides were analyzed with micro-CT, histomorphometry, and immunohistochemistry. On the right side, bone markers gene expression was analyzed by qPCR. ZOL increased the percentage of necrotic bone and reduced the neo-formed bone compared to groups not receiving ZOL (p < 0.05). RES impacted the tissue healing pattern in OVX + ZOL + RES, reduced inflammatory cell infiltrate, and improved bone formation in the extraction site. Osteoblasts, alkaline phosphatase (ALP)-, and osteocalcin (OCN)-immunoreactive cells were lower in OVX-ZOL than in SHAM, OVX, and OVX-RES. The OXV-ZOL-RES had fewer osteoblasts and ALP- and OCN-cells than the SHAM and OVX-RES. The tartrate-resistant acid phosphatase (TRAP)-positive cells were reduced in the presence of ZOL (p < 0.05), while the TRAP mRNA levels increased with ZOL treatment, with or without resveratrol, compared with the other groups (p < 0.05). RES alone increased superoxide dismutase levels compared to OVX + ZOL and OVX + ZOL + RES (p < 0.05). In conclusion, resveratrol reduced the tissue impairment severity induced by ZOL; however, it could not prevent the occurrence of MRONJ.
Collapse
Affiliation(s)
- Marcelo Vitale
- Dental Research Division, School of Dentistry, Paulista University, São Paulo, Brazil
| | | | - Edilson Ervolino
- Department of Basic Sciences, Dental School of Araçatuba, University Estadual Paulista, UNESP, Araçatuba, Brazil
| | | | | | | | | | - Suzana Peres Pimentel
- Dental Research Division, School of Dentistry, Paulista University, São Paulo, Brazil
| |
Collapse
|
4
|
Jiang A, Zhang Z, Qiu X, Guo Q. Medication-related osteonecrosis of the jaw (MRONJ): a review of pathogenesis hypothesis and therapy strategies. Arch Toxicol 2024; 98:689-708. [PMID: 38155341 DOI: 10.1007/s00204-023-03653-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ), a severe side effect caused by antiresorptive antiangiogenic medication, particularly bisphosphonates (BPs), has become a challenging disease with serious and profound effects on the physical and mental health of patients. Although it occurs with high frequency and is harmful, the exact mechanism of MRONJ remains unknown, and systematic and targeted approaches are still lacking. Maxillofacial surgeons focus on the etiology of osteonecrosis in the mandible and maxilla as well as the appropriate oral interventions for high-risk patients. Adequate nursing care and pharmacotherapy management are also crucial. This review provides a current overview of the clinicopathologic feature and research of MRONJ caused by BPs, with an emphasis on the potential mechanisms and current therapy and prevention strategies of the disease. We are of the opinion that an in-depth comprehension of the mechanisms underlying MRONJ will facilitate the development of more precise and efficacious therapeutic approaches, resulting in enhanced clinical outcomes for patients.
Collapse
Affiliation(s)
- Aiming Jiang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China School of Stomatology, Sichuan University, No. 14, Section 3, South Renmin Road, Chengdu, China
| | - Zhuoyuan Zhang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China School of Stomatology, Sichuan University, No. 14, Section 3, South Renmin Road, Chengdu, China
- Department of Head and Neck Cancer Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xutong Qiu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China School of Stomatology, Sichuan University, No. 14, Section 3, South Renmin Road, Chengdu, China.
- Department of Head and Neck Cancer Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
| | - Qiang Guo
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China School of Stomatology, Sichuan University, No. 14, Section 3, South Renmin Road, Chengdu, China.
| |
Collapse
|
5
|
Nogueira D, Caldas IM, Dinis-Oliveira RJ. Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects. Arch Oral Biol 2023; 155:105792. [PMID: 37611492 DOI: 10.1016/j.archoralbio.2023.105792] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/30/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis. DESIGN An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject. RESULTS MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered. CONCLUSIONS Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.
Collapse
Affiliation(s)
- Diana Nogueira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal.
| | - Inês Morais Caldas
- Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; Centre for Functional Ecology (CFE), Department of Life Sciences, University of Coimbra, Calçada Martim de Freitas, 3000-456 Coimbra, Portugal.
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; UCIBIO/REQUIMTE, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, R. Jorge Viterbo Ferreira, No 228, 4050-313 Porto, Portugal.
| |
Collapse
|
6
|
Sawada S, Sakamoto Y, Kirihigashi M, Kojima Y. Drug holiday of high-dose denosumab and recovery from osteoclast inhibition using immunohistochemical investigation of 7 patients with medication-related osteonecrosis of the jaw undergoing segmental mandibulectomy. J Dent Sci 2023; 18:1645-1650. [PMID: 37799892 PMCID: PMC10547948 DOI: 10.1016/j.jds.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/20/2023] [Indexed: 02/13/2023] Open
Abstract
Background/purpose Denosumab is used to treat bone metastases from malignant tumors. Unlike bisphosphonates, denosumab is not deposited in the bone; thus, withdrawal for a relatively short period would help recovery from osteoclast suppression. This study investigated the relationship between drug holidays and recovery from osteoclast suppression. Materials and methods Seven patients who received high-dose denosumab and underwent segmental mandibulectomy for medication-related osteonecrosis of the jaw were enrolled in this study. Osteoclast suppression (+) was defined as the absence of cathepsin K-positive cells or cathepsin K-positive mononuclear or small multinucleated cells observed on the bone surface of both mesial and distal specimens. When normal osteoclasts were found, osteoclast suppression was defined as (-); when both suppressed cathepsin K-positive cells and normal morphological osteoclasts were found, it was defined as (±). Results Osteoclast suppression was: (+) in four patients, three without a drug holiday and one with a 9-month drug holiday; (±) in one patient with an 8-month drug holiday, and (-) in two patients with drug holidays for 13 and 20 months. Conclusion These findings suggest that a long-term drug holiday, such as 12 months, is required for recovery from osteoclast suppression in patients with cancer receiving high-dose denosumab.
Collapse
Affiliation(s)
- Shunsuke Sawada
- Department of Dentistry and Oral Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Yuki Sakamoto
- Department of Dentistry and Oral Surgery, Kansai Medical University Medical Center, Osaka, Japan
| | - Mako Kirihigashi
- Department of Dentistry and Oral Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Yuka Kojima
- Department of Dentistry and Oral Surgery, Kansai Medical University Hospital, Osaka, Japan
| |
Collapse
|
7
|
Liu FC, Luk KC, Chen YC. Risk comparison of osteonecrosis of the jaw in osteoporotic patients treated with bisphosphonates vs. denosumab: a multi-institutional retrospective cohort study in Taiwan. Osteoporos Int 2023; 34:1729-1737. [PMID: 37326685 PMCID: PMC10511380 DOI: 10.1007/s00198-023-06818-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
In this multi-institutional retrospective cohort study, we compared the long-term risk of osteonecrosis of the jaw following the use of denosumab vs. bisphosphonates in osteoporotic patients. After 2-year use, the likelihood of osteonecrosis of the jaw is lower with denosumab compared to bisphosphonates, and the difference increases with time. PURPOSE To compare the long-term risk of osteonecrosis of the jaw (ONJ) between osteoporotic patients treated with bisphosphonates (BPs) and denosumab. METHODS This multi-institutional retrospective cohort study included patients aged > 40 years with osteoporosis between January 2010 and December 2018. Patients who met the eligibility criteria were divided into BPs and denosumab groups by propensity score matching (PSM). The risk of ONJ of denosumab vs. BPs was estimated using a Cox proportional hazards model and was described by the cumulative incidence rate using the Kaplan-Meier method. RESULTS A total of 84,102 patients with osteoporosis were enrolled, among whom, 8962 were eligible for inclusion based on their first-line drug use (denosumab, n = 3,823; BPs, n = 5,139). Following PCM matching (1:1), the BPs and denosumab groups included 3665 patients each. The incidence density of ONJ in the denosumab and BPs matching groups was 1.47 vs. 2.49 events (per 1000 person-years), respectively. The hazard ratio of ONJ in the denosumab vs. BPs group was estimated as 0.581 (95% confidence interval: 0.33-1.04, p = 0.07). The cumulative incidence rates of ONJ in both groups were similar for the first and second years of drug use (p = 0.062), but significantly different from the third year onwards (p = 0.022). The severity of ONJ was not significantly different between the two groups. CONCLUSION In osteoporotic patients, after 2 years of use, the likelihood of ONJ being induced by denosumab is lower than that of BPs, and the difference increases with time.
Collapse
Affiliation(s)
- Fang-Chun Liu
- Department of Dentistry, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kwing-Chi Luk
- Department of Dentistry, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yung-Chih Chen
- Division of General Internal Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
8
|
Tetradis S, Allen MR, Ruggiero SL. Pathophysiology of Medication-Related Osteonecrosis of the Jaw-A Minireview. JBMR Plus 2023; 7:e10785. [PMID: 37614299 PMCID: PMC10443081 DOI: 10.1002/jbm4.10785] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious adverse effect of antiresorptive medications administered for control of osseous malignancy, osteoporosis, or other bone metabolic diseases. Despite being reported in the literature two decades ago, MRONJ etiology, pathophysiology, and progression remain largely unknown, and current nonoperative or operative treatment strategies are mostly empirical. Several hypotheses that attempt to explain the mechanisms of MRONJ pathogenesis have been proposed. However, none of these hypotheses alone is able to capture the complex mechanistic underpinnings of the disease. In this minireview, we aim to highlight key findings from clinical and translational studies and propose a unifying model for the pathogenesis and progression of MRONJ. We also identify aspects of the disease process that require further investigation and suggest areas for future research efforts toward calibrating methodologic approaches and validating experimental findings. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Sotirios Tetradis
- Division of Diagnostic and Surgical SciencesUCLA School of DentistryLos AngelesCAUSA
| | - Matthew R. Allen
- Department of Anatomy, Cell Biology & PhysiologyIndiana University School of MedicineIndianapolisINUSA
| | - Salvatore L. Ruggiero
- New York Center for Orthognathic and Maxillofacial SurgeryLake SuccessNYUSA
- Department Oral and Maxillofacial SurgeryStony Brook School of Dental MedicineStony BrookNYUSA
- Division of Oral and Maxillofacial SurgeryHofstra‐Northwell School of MedicineHempsteadNYUSA
| |
Collapse
|
9
|
Yasui T, Nagamine H, Tanaka K, Kimura M, Karube T, Kawana H, Onizawa K. Treatment outcomes and time to healing of medication-related osteonecrosis of the jaw based on image findings. Dentomaxillofac Radiol 2023; 52:20220352. [PMID: 37192041 PMCID: PMC10304842 DOI: 10.1259/dmfr.20220352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the prognostic treatment outcome of non-operative management of medication-related osteonecrosis of the jaw (MRONJ), particularly regarding the relationship between image findings and treatment outcomes. METHODS This single-center, retrospective observational study included patients with MRONJ who were conservatively treated between 2010 and 2020. All patients were evaluated in terms of MRONJ treatment outcomes, time to healing, and prognostic factors, including sex, age, underlying disease, antiresorptive drug type, discontinuation of antiresorptive treatment, chemotherapy, corticosteroid treatment, diabetes mellitus, location of MRONJ, clinical stage of MRONJ, and computed tomography image findings. RESULTS The complete healing rate among the patients was 68.5%. Cox proportional hazards regression analysis revealed that "Sequestrum formation" on the internal texture (hazard ratio = 3.66; 95% confidence interval, 1.30-10.29; P =.014) and chemotherapy (hazard ratio = 0.41; 95% confidence interval, 0.18-0.95; P =.037) were significantly associated with treatment outcome. The median time to healing in patients with "Sequestrum formation" on the internal texture (4.4 months) was significantly shorter than the median time to healing in those marked with "Sclerosis" or "Normal" (35.5 months; P <.001) and "Lytic changes with sclerosis" (14.5 months; P =.015). CONCLUSIONS The image findings on the internal texture of the lesions at the initial examination and chemotherapy were associated with the treatment outcomes of nonoperative management of MRONJ. The image findings of "Sequestrum formation" were associated with lesions taking a short time to heal and better outcomes, whereas "Sclerosis" and "Normal" were associated with lesions with longer healing times.
Collapse
Affiliation(s)
| | - Hiroki Nagamine
- Department of Dentistry and Oral Surgery, Federation of National Public Service Personnel Mutual Aid Associations Tachikawa Hospital, Tokyo, Japan
| | - Kenta Tanaka
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Moemi Kimura
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Ida Hospital, Kawasaki, Japan
| | - Takeshi Karube
- Department of Dentistry and Oral Surgery, School of Medicine, Keio University, Tokyo, Japan
| | | | - Katsuhiro Onizawa
- Department of Dentistry and Oral Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| |
Collapse
|
10
|
Straub A, Stapf M, Fischer M, Vollmer A, Linz C, Lâm TT, Kübler A, Brands RC, Scherf-Clavel O, Hartmann S. Bone Concentration of Ampicillin/Sulbactam: A Pilot Study in Patients with Osteonecrosis of the Jaw. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14917. [PMID: 36429636 PMCID: PMC9690242 DOI: 10.3390/ijerph192214917] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 06/16/2023]
Abstract
Osteonecrosis of the jaw (ONJ) occurs typically after irradiation of the head and neck area or after the intake of antiresorptive agents. Both interventions can lead to compromised bone perfusion and can ultimately result in infection and necrosis. Treatment usually consists of surgical necrosectomy and prolonged antibiotic therapy, usually through beta-lactams such as ampicillin/sulbactam. The poor blood supply in particular raises the question as to whether this form of antibiosis can achieve sufficient concentrations in the bone. Therefore, we investigated the antibiotic concentration in plasma and bone samples in a prospective study. Bone samples were collected from the necrosis core and in the vital surrounding bone. The measured concentrations in plasma for ampicillin and sulbactam were 126.3 ± 77.6 and 60.2 ± 35.0 µg/mL, respectively. In vital bone and necrotic bone samples, the ampicillin/sulbactam concentrations were 6.3 ± 7.8/1.8 ± 2.0 µg/g and 4.9 ± 7.0/1.7 ± 1.7 µg/g, respectively. These concentrations are substantially lower than described in the literature. However, the concentration seems sufficient to kill most bacteria, such as Streptococci and Staphylococci, which are mostly present in the biofilm of ONJ. We, therefore, conclude that intravenous administration of ampicillin/sulbactam remains a valuable treatment in the therapy of ONJ. Nevertheless, increasing resistance of Escherichia coli towards beta-lactam antibiotics have been reported and should be considered.
Collapse
Affiliation(s)
- Anton Straub
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Maximilian Stapf
- Institute for Pharmacy and Food Chemistry, University of Wuerzburg, Am Hubland, 97074 Wuerzburg, Germany
| | - Markus Fischer
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Andreas Vollmer
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Christian Linz
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Thiên-Trí Lâm
- Institute for Hygiene and Microbiology, University of Wuerzburg, Josef-Schneider-Str. 2/E1, 97080 Wuerzburg, Germany
| | - Alexander Kübler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Roman C. Brands
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| | - Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Wuerzburg, Am Hubland, 97074 Wuerzburg, Germany
| | - Stefan Hartmann
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Wuerzburg, Pleicherwall 2, 97070 Wuerzburg, Germany
| |
Collapse
|
11
|
Otsuru M, Hayashida S, Morishita K, Murata M, Soutome S, Sasaki M, Takagi Y, Sumi M, Umeda M. Retrospective Analysis of Treatment Outcomes of Maxillary Sinusitis Associated with Medication-Related Osteonecrosis of the Jaw. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127430. [PMID: 35742679 PMCID: PMC9224189 DOI: 10.3390/ijerph19127430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 12/17/2022]
Abstract
Although maxillary sinusitis often occurs in patients with medication-related osteonecrosis of the jaw (MRONJ) of the upper jaw, there have been few reports on the treatment and outcomes for maxillary sinusitis associated with maxillary MRONJ. This study aimed to retrospectively investigate the treatment outcomes of maxillary sinusitis in patients with MRONJ of the upper jaw. There were 34 patients diagnosed with maxillary MRONJ and sinusitis by preoperative computed tomography who underwent surgery in our institution between January 2011 and December 2019. Age, sex, primary disease, stage of MRONJ, class and administration period of an antiresorptive agent, corticosteroid administration, preoperative leukocyte count and serum albumin level, periosteal reaction, sinusitis grade, maxillary sinus surgical procedure, and treatment outcomes of MRONJ and sinusitis were examined. There were 7 male and 27 female patients (average age, 74.7 years). Complete healing of MRONJ was obtained in 29 of 34 patients (85.3%). Maxillary sinusitis resolved or improved in 21 patients (61.8%) but did not change or worsen in 13 patients (38.2%). We found that complete resection of necrotic bone with intraoperative irrigation of the maxillary sinus may provide good treatment outcomes for maxillary sinusitis associated with MRONJ, although our findings were not statistically significant owing to the small number of patients.
Collapse
Affiliation(s)
- Mitsunobu Otsuru
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (S.H.); (K.M.); (M.M.); (M.U.)
- Correspondence: ; Tel.: +81-95-819-7698
| | - Saki Hayashida
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (S.H.); (K.M.); (M.M.); (M.U.)
| | - Kota Morishita
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (S.H.); (K.M.); (M.M.); (M.U.)
| | - Maho Murata
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (S.H.); (K.M.); (M.M.); (M.U.)
| | - Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan;
| | - Miho Sasaki
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (M.S.); (Y.T.); (M.S.)
| | - Yukinori Takagi
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (M.S.); (Y.T.); (M.S.)
| | - Misa Sumi
- Department of Radiology and Biomedical Informatics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (M.S.); (Y.T.); (M.S.)
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8588, Japan; (S.H.); (K.M.); (M.M.); (M.U.)
| |
Collapse
|
12
|
Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg 2022; 80:920-943. [PMID: 35300956 DOI: 10.1016/j.joms.2022.02.008] [Citation(s) in RCA: 263] [Impact Index Per Article: 131.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/13/2022]
Abstract
Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaws (MRONJ) - formerly referred to as bisphosphonate-related osteonecrosis of the jaws (BRONJ)-were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007, 2009 and 2014. The position papers were developed by a committee appointed by the AAOMS Board of Trustees and comprising clinicians with extensive experience in caring for these patients, as well as clinical and basic science researchers. The knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating modifications and refinements to the previous position papers. Three members of the AAOMS Committee on Oral, Head, and Neck Oncologic and Reconstructive Surgery (COHNORS) and three authors of the 2014 position paper were appointed to serve as a working group to analyze the current literature and revise the guidance as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis and management strategies and highlights the current research status. AAOMS maintains that it is vitally important for this information to be disseminated to other relevant healthcare professionals and organizations.
Collapse
Affiliation(s)
- Salvatore L Ruggiero
- Clinical Professor, Division of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Hofstra North Shore-LIJ School of Medicine, New York Center for Orthognathic and Maxillofacial Surgery, Lake Success, NY.
| | - Thomas B Dodson
- Professor and Chair, University of Washington School of Dentistry, Department of Oral and Maxillofacial Surgery, Seattle, Wash
| | - Tara Aghaloo
- Professor, Oral and Maxillofacial Surgery, UCLA School of Dentistry, Los Angeles, Calif
| | - Eric R Carlson
- Professor and Kelly L. Krahwinkel Endowed Chairman, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Brent B Ward
- Chalmers J Lyons Professor of Oral and Maxillofacial Surgery, Associate Professor of Dentistry, Chair of the Department of Oral and Maxillofacial Surgery/Hospital Dentistry in the School of Dentistry and Associate Professor of Surgery for the Medical School, University of Michigan Hospital, Ann Arbor, Mich
| | - Deepak Kademani
- Chief of Staff North Memorial Health, Fellowship Director, Oral/Head and Neck Oncologic and Reconstructive Surgery Attending Surgeon, North Memorial Health and the University of Minnesota. Private practice, Minnesota Oral and Facial Surgery and Minnesota Head and Neck Surgery, Minneapolis, Minn
| |
Collapse
|
13
|
Macrophage Involvement in Medication-Related Osteonecrosis of the Jaw (MRONJ): A Comprehensive, Short Review. Cancers (Basel) 2022; 14:cancers14020330. [PMID: 35053492 PMCID: PMC8773732 DOI: 10.3390/cancers14020330] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Medication-related Osteonecrosis of the Jaw (MRONJ) is a significant complication mainly of antiresorptive medications used in the management of bone diseases. MRONJ development may be accompanied by pain, eating discomfort, self-consciousness, and other symptoms that overall disturb patients’ everyday life. Hence, MRONJ occurrence is of growing clinical concern and affects treatment decisions. Although MRONJ has been extensively studied since being first reported in 2003, the mechanisms of disease pathogenesis have not yet been determined and disease management is mostly empirical. Recent data investigate the effects of antiresorptive medications on immune system components including macrophages and introduce these cells as key players in MRONJ pathogenesis. Considering macrophage versatility, developmental plasticity, and its pivotal role in immune response, the current short review focused on the potential involvement of these multi-potential cells in MRONJ pathogenesis. Understanding the complex role of macrophages in MRONJ pathophysiology will add new valuable data on disease prevention and control. Abstract Antiresorptive agents such as bisphosphonates (BP) and denosumab are commonly prescribed for the management of primary bone malignancy, bone metastasis, osteoporosis, Paget disease, or other bone disorders. Medication-related osteonecrosis of the Jaws (MRONJ) is a rare but significant complication of antiresorptive medications. Duration, dose, and antiresorptive potency as well as concomitant diseases, additional medications, and local factors affect MRONJ incidence and severity. MRONJ pathophysiology is still poorly understood. Nevertheless, decreased bone resorption due to osteoclastic inhibition along with trauma, infection/inflammation, or blood supply inhibition are considered synergistic factors for disease development. In addition, previous data research examined the effects of antiresorptive medication on immune system components and introduced potential alterations on immune response as novel elements in MRONJ pathogenesis. Considering that macrophages are the first cells in the nonspecific immune response, it is not surprising that these multifaceted players attracted increased attention in MRONJ research recently. This current review attempted to elucidate the effects of antiresorptive medications on several aspects of macrophage activity in relation to the complex inflammatory microenvironment of MRONJ. Collectively, unravelling the mode of action and extent of macrophages’ potential contribution in MRONJ occurrence will provide novel insight in disease pathogenesis and potentially identify intrinsic therapeutic targets.
Collapse
|
14
|
Medication-Related Osteonecrosis of the Jaw: A Critical Narrative Review. J Clin Med 2021; 10:jcm10194367. [PMID: 34640383 PMCID: PMC8509366 DOI: 10.3390/jcm10194367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Nearly two decades have passed since a paradoxical reaction in the orofacial region to some bone modifying agents and other drugs was recognized, namely medication-related osteonecrosis of the jaw (MRONJ). Purpose: The aim of this manuscript was to critically review published data on MRONJ to provide an update on key terminology, concepts, and current trends in terms of prevention and diagnosis. In addition, our objective was to examine and evaluate the therapeutic options available for MRONJ. Methods: The authors perused the most relevant literature relating to MRONJ through a search in textbooks and published articles included in several databases for the years 2003–2021. Results and conclusions: A comprehensive update of the current understanding of these matters was elaborated, addressing these topics and identifying relevant gaps of knowledge. This review describes our updated view of the previous thematic blocks, highlights our current clinical directions, and emphasizes controversial aspects and barriers that may lead to extending the accumulating body of evidence related to this severe treatment sequela.
Collapse
|
15
|
Kaibuchi N, Hoshi K, Yamazaki A, Miyamoto-Sangu N, Akagi Y, Okamoto T. The progress of medication-related osteonecrosis of the jaw with conservative initial treatment: A 12-year retrospective study of 129 patients. Bone Rep 2021; 14:101072. [PMID: 33997149 PMCID: PMC8100074 DOI: 10.1016/j.bonr.2021.101072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022] Open
Abstract
This retrospective study aimed to examine the course and prognosis of medication-related osteonecrosis of the jaw (MRONJ) initially treated conservatively and the effects of various factors affecting treatment outcomes. We evaluated 129 patients with MRONJ between January 2008 and December 2018 at a university hospital. The factors examined included sex, age, stage of MRONJ (1-3), type of bone modifying agents (bisphosphonate or denosumab), primary disease (osteoporosis or malignant tumor), medical history (diabetes and rheumatoid arthritis), use of corticosteroids, the trigger of MRONJ (teeth extraction or others), and separation of sequestrum, using logistic regression analysis. Patients with MRONJ were treated conservatively as the initial treatment in accordance with the position paper of the American Association of Oral and Maxillofacial Surgeons. Of the 129 patients, 59 (45.7%) were cured, and the condition of 70 (54.3%) remained unchanged or worsened. The overall cure rates at 12, 36, and 60 months were 25.8%, 50.8%, and 72.4% respectively. The cure rate of stage 1 was lower than that of stages 2 and 3 at 80 months. In multivariate analysis, it was found that 37 (64.9%) of 57 patients with osteoporosis as a primary disease were cured (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.4-24.4). In addition, 40 (69.0%) of 58 patients with separation of sequestrum were cured (OR, 8.9; 95% CI, 3.4-23.5). The cure rate was significantly higher in patients with osteoporosis than in those with cancer when the treatment outcomes of primary disease were compared using the Kaplan-Meier method (p < 0.01). It was also significantly higher in patients who had separation of sequestrum than in those who did not (p < 0.05). Our results suggest that primary disease and separation of sequestrum were associated with favorable outcomes in patients with MRONJ initially treated conservatively. MRONJ had a poor prognosis with conventional treatment carried according to the stage of the disease. This was especially prominent when conservative treatment was employed for mild cases.
Collapse
Affiliation(s)
- Nobuyuki Kaibuchi
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.,Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University (TWIns), 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Keika Hoshi
- National Institute of Public Health, Center for Public Health Informatics, 2-3-6 Minami, Wako, Saitama 351-0197, Japan.,Department of Hygiene, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Ayame Yamazaki
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Noriko Miyamoto-Sangu
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Yuichi Akagi
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Toshihiro Okamoto
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| |
Collapse
|
16
|
Varoni EM, Lombardi N, Villa G, Pispero A, Sardella A, Lodi G. Conservative Management of Medication-Related Osteonecrosis of the Jaws (MRONJ): A Retrospective Cohort Study. Antibiotics (Basel) 2021; 10:antibiotics10020195. [PMID: 33671429 PMCID: PMC7922963 DOI: 10.3390/antibiotics10020195] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of bisphosphonates and anti-resorptive drugs prescribed for treatment of severe osteoporosis, Paget's disease, and bone malignancies. The aim of this study was to evaluate the clinical outcome of a combined pharmacological and surgical management strategy on patients affected by MRONJ. MATERIALS AND METHODS Medical records of patients with MRONJ were retrospectively examined to collect clinical history data. Conservative management included an initial pharmacological phase with antibiotics and antiseptic agents, followed by surgical intervention to remove bone sequestrum. Primary outcomes were healing from MRONJ at short term (1 month after surgery) and at longer term (3 months after surgery). Secondary outcome was assessment of recurrences at longer-term follow-up. RESULTS Thirty-five patients were included in the study with mean follow-up of 23.86 ± 18.14 months. Seven cases showed spontaneous exfoliation of necrotic bone during pharmacological therapy, which in one case did not require any further intervention. At 1-month posttreatment, 31 out of 35 (88.5%) patients showed complete healing. The 25 patients who were followed for at least 3 months revealed a healing rate of 92% (23/25). Recurrences occurred in 7 patients out 23 who showed the long-term healing, after a mean period of 7.29 ± 3.45 months. The prognostic score (University of Connecticut Osteonecrosis Numerical Scale-UCONNS) was significantly higher (p = 0.01) in patients with poor healing as compared to complete healing, both at 1 and 3 months posttreatment. CONCLUSIONS A MRONJ treatment approach based on a combined pharmacological and surgical treatment strategy showed a high rate of healing and few recurrences.
Collapse
|
17
|
Hadaya D, Soundia A, Gkouveris I, Bezouglaia O, Dry SM, Pirih FQ, Aghaloo TL, Tetradis S. Antiresorptive-Type and Discontinuation-Timing Affect ONJ Burden. J Dent Res 2021; 100:746-753. [PMID: 33478337 DOI: 10.1177/0022034520986804] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Osteonecrosis of the jaws (ONJ), a severe side effect of antiresorptive medications, is characterized by exposed, nonhealing bone in the oral cavity. Treatment options for ONJ range from management of symptomology to surgical resection of the affected area. Antiresorptive discontinuation, often termed a "drug holiday," has been used for managing ONJ patients. Antiresorptives can be discontinued prior to oral surgical procedures, such as tooth extraction, to prevent ONJ development or in patients with established ONJ to accelerate healing. Here, our objective was to test these clinical scenarios using the potent bisphosphonate, zoledronic acid (ZA), and the denosumab surrogate for rodents, OPG-Fc, in a rat model of ONJ. Animals were pretreated with antiresorptives or saline, after which we induced ONJ using periapical disease and tooth extraction. In our first experimental design, antiresorptives were discontinued 1 wk prior to tooth extraction, and animals were evaluated 4 wk later for clinical, radiographic, and histologic features of ONJ. In the second experiment, ONJ was established and antiresorptives were discontinued for 4 wk. Discontinuation of OPG-Fc, but not ZA, prior to tooth extraction ameliorated subsequent ONJ development. In contrast, discontinuation of either ZA or OPG-Fc in rats with established ONJ did not lead to ONJ resolution. In conclusion, our findings suggest that antiresorptive discontinuation is dependent on both the type of antiresorptive and the timing of discontinuation.
Collapse
Affiliation(s)
- D Hadaya
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - A Soundia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - I Gkouveris
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - O Bezouglaia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - S M Dry
- UCLA Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - F Q Pirih
- Division of Constitutive and Regenerative Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - T L Aghaloo
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - S Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| |
Collapse
|
18
|
Govaerts D, Piccart F, Ockerman A, Coropciuc R, Politis C, Jacobs R. Adjuvant therapies for MRONJ: A systematic review. Bone 2020; 141:115676. [PMID: 33022455 DOI: 10.1016/j.bone.2020.115676] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction caused by the use of antiresorptive antiangiogenic medication. Treating MRONJ is difficult and besides standard treatments, which are conservative medical and surgical approaches, there are some adjuvant therapies that might further stimulate healing. The aim of this systematic review is to compare outcome and effectiveness of currently available adjuvant therapies for MRONJ. METHODS This systematic review was conducted following the PRISMA guidelines. Articles focusing on mucosal healing in patients treated with an adjuvant therapy for MRONJ were selected and analysed. Inclusion was not limited to randomized controlled trials to present a complete review of the current literature. RESULTS A search was performed in Pubmed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Thirty articles out of 3297 were included. Laser ablation had a success of 60-95% for complete healing. The controlled trials of leukocyte- and platelet-rich-fibrine (LPRF) showed 60-100% success for the same outcome. Fluorescence guided surgery had a complete healing percentage of 85-90%. CONCLUSIONS The results suggest that laser ablation, LPRF and fluorescence guided surgery might have a potential in improving the healing process. Interpreting the results should however be done with great care and a critical point of view, as most articles had a medium to high risk of bias. More randomized controlled trials are necessary to define the most beneficial therapy protocols. CLINICAL RELEVANCE It seems that adjuvant surgical therapies for treating MRONJ are beneficial for mucosal healing, but there is only low scientific evidence.
Collapse
Affiliation(s)
- Dries Govaerts
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frederik Piccart
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anna Ockerman
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium
| | - Ruxandra Coropciuc
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden.
| |
Collapse
|
19
|
Wan JT, Sheeley DM, Somerman MJ, Lee JS. Mitigating osteonecrosis of the jaw (ONJ) through preventive dental care and understanding of risk factors. Bone Res 2020; 8:14. [PMID: 32195012 PMCID: PMC7064532 DOI: 10.1038/s41413-020-0088-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/31/2019] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
It is well established that alterations in phosphate metabolism have a profound effect on hard and soft tissues of the oral cavity. The present-day clinical form of osteonecrosis of the jaw (ONJ) was preceded by phosphorus necrosis of the jaw, ca. 1860. The subsequent removal of yellow phosphorus from matches in the early 20th century saw a parallel decline in "phossy jaw" until the early 2000s, when similar reports of unusual jaw bone necrosis began to appear in the literature describing jaw necrosis in patients undergoing chemotherapy and concomitant steroid and bisphosphonate treatment. Today, the potential side effect of ONJ associated with medications that block osteoclast activity (antiresorptive) is well known, though the mechanism remains unclear and the management and outcomes are often unsatisfactory. Much of the existing literature has focused on the continuing concerns of appropriate use of bisphosphonates and other antiresorptive medications, the incomplete or underdeveloped research on ONJ, and the use of drugs with anabolic potential for treatment of osteoporosis. While recognizing that ONJ is a rare occurrence and ONJ-associated medications play an important role in fracture risk reduction in osteoporotic patients, evidence to date suggests that health care providers can lower the risk further by dental evaluations and care prior to initiating antiresorptive therapies and by monitoring dental health during and after treatment. This review describes the current clinical management guidelines for ONJ, the critical role of dental-medical management in mitigating risks, and the current understanding of the effects of predominantly osteoclast-modulating drugs on bone homeostasis.
Collapse
Affiliation(s)
- Jason T. Wan
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD USA
| | - Douglas M. Sheeley
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD USA
| | - Martha J. Somerman
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD USA
- Laboratory for Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD USA
| | - Janice S. Lee
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD USA
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Gkouveris I, Hadaya D, Soundia A, Bezouglaia O, Chau Y, Dry SM, Pirih FQ, Aghaloo TL, Tetradis S. Vasculature submucosal changes at early stages of osteonecrosis of the jaw (ONJ). Bone 2019; 123:234-245. [PMID: 30953717 PMCID: PMC6763394 DOI: 10.1016/j.bone.2019.03.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/16/2019] [Accepted: 03/22/2019] [Indexed: 02/09/2023]
Abstract
Osteonecrosis of the jaw (ONJ), a rare, but potentially severe side effect of anti-resorptive medications, presents as exposed bone in the maxillofacial region lasting for at least 8 weeks. While clinical experience and animal models concur in finding that systemic antiresorptive treatment in conjunction with local risk factors, such as tooth extraction or dental disease may lead to ONJ development, the subclinical molecular changes that precede bone exposure remain poorly understood. The identification of these changes is not only important in understanding disease pathophysiology, but could provide potential for treatment development. Here, we evaluated the early stages of ONJ utilizing a model of experimental periodontitis (EP) in mice treated with two different types of antiresorptives, targeting potential changes in vasculature, hypoxia, oxidative stress, and apoptosis. Antiresorptive treatment in animals with EP increased levels of empty osteocytic lacunae and increased ONJ prevalence compared to Veh animals. The arteriole and venule network seen around EP areas was diminished in animals treated with antiresorptives. Higher levels of vascular endothelial growth factor A (VEGF-A) and vascular cell adhesion protein-1 (VCAM-1) were observed 1-week following EP in treated animals. Finally, levels of hypoxia, oxidative stress, and apoptosis remained high in antiresorptive treated animals with EP through the duration of the experiment. Together, our data point to subclinical vasculature organizational disturbances that subsequently affect levels of hypoxia, oxidative stress, and apoptosis in the area of developing ONJ.
Collapse
Affiliation(s)
- Ioannis Gkouveris
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Danny Hadaya
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Akrivoula Soundia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Olga Bezouglaia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Yee Chau
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Sarah M Dry
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Flavia Q Pirih
- Division of Constitutive and Regenerative Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Tara L Aghaloo
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA.
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA.
| |
Collapse
|
22
|
Nishida T, Fujita Y, Myoken Y. Comment on “Nonsurgical Management of Medication-Related Osteonecrosis of the Jaws Using Local Wound Care” by Hadaya et al. J Oral Maxillofac Surg 2019; 77:885-886. [DOI: 10.1016/j.joms.2018.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/14/2018] [Indexed: 11/28/2022]
|
23
|
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: 50] [Impact Index Per Article: 8.3] [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.
Collapse
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
| |
Collapse
|