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The Treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Systematic Review with a Pooled Analysis of Only Surgery versus Combined Protocols. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168432. [PMID: 34444181 PMCID: PMC8392050 DOI: 10.3390/ijerph18168432] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 01/03/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction of antiresorptive and antiangiogenic agents, and it is also a potentially painful and debilitating condition. To date, no specific studies have prospectively evaluated the efficacy of its treatment and no robust standard of care has been established. Therefore, a systematic review (2007–2020) with a pooled analysis was performed in order to compare MRONJ surgical techniques (conservative or aggressive) versus combined surgical procedures (surgery plus a non-invasive procedure), where 1137 patients were included in the pooled analysis. A statistically significant difference in the 6-month improvement rate, comparing combined conservative surgery versus only aggressive (91% versus 72%, p = 0.05), was observed. No significant difference regarding any group with respect to the 6-month total resolution rate (82% versus 72%) was demonstrated. Of note, conservative surgery combined with various, adjuvant, non-invasive procedures (ozone, LLLT or blood component + Nd:YAG) was found to achieve partial or full healing in all stages, with improved results and the amelioration of many variables. In conclusion, specific adjuvant treatments associated with minimally conservative surgery can be considered effective and safe in the treatment of MRONJ, although well-controlled studies are a requisite in arriving at definitive statements
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Fluorescence-guided surgical debridement of chronic osteomyelitis utilizing doxycycline bone labeling: a technical trick revived. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tomo S, da Cruz TM, Figueira JA, Cunha JLS, Miyahara GI, Simonato LE. Fluorescence-guided surgical management of medication-related osteonecrosis of the jaws. Photodiagnosis Photodyn Ther 2020; 32:102003. [PMID: 32916330 DOI: 10.1016/j.pdpdt.2020.102003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/15/2020] [Accepted: 09/04/2020] [Indexed: 12/12/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) results in progressive destruction of the jawbones, and advanced cases demand surgical intervention. The total removal of necrotic bone is required to prevent recurrence and infection. However, determining the limits between necrotic and healthy bone is a challenge. The use of fluorescence to detect tissue alterations and determine necrosis extension is a promising method to avoid inadequate bone debridement. In the literature, there are several studies and reported cases that successfully use fluorescence-guided surgery (FGS) of MRONJ. The objective of this study was to present a critical review of the literature regarding the intraoperative use of optic fluorescence to differentiate healthy and necrotic bone in MRONJ. Studies that evaluated the intraoperative use of optic fluorescence to determine the surgical margins of MRONJ were searched in Pubmed/Medline and Scopus databases using the following terms: "medication-related osteonecrosis of the jaws" and "fluorescence". Eighteen papers describing the intraoperative use of FGS in ONJ management were selected, totalizing 218 patients. Of those 18 papers, only 5 were prospective studies, and the other 13 were isolated case reports, case series, and technical notes. The use of FGS to delimitate the resection margin of MRONJ is a promising method. There is no need for the application of exogenous fluorophore to perform FGS and the most often used light device was the VELScope® system. Further prospective studies with larger samples are still required to ascertain the fluorescence validity as a supporting method in MRONJ surgical treatment and to establish clinical protocols.
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Affiliation(s)
- Saygo Tomo
- Oral Oncology Center, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil; Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil.
| | | | - Jéssica Araújo Figueira
- Oral Oncology Center, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil; Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil
| | - John Lennon Silva Cunha
- Oral Pathology Section, Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil
| | - Glauco Issamu Miyahara
- Oral Oncology Center, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil; Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil
| | - Luciana Estevam Simonato
- Postgraduate Program in Bioengineering, Universidade Brasil, São Paulo, Brazil; Dental School, University Brasil, Fenandópolis, SP, Brazil
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Ballardin C, Pereira-Stabile CL, Stabile GAV. Use of a generic violet light in the surgical management of medication-related osteonecrosis of the jaws: a technical note. Oral Maxillofac Surg 2018; 22:477-481. [PMID: 30173371 DOI: 10.1007/s10006-018-0718-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/28/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Fluorescence-guided surgery has been recommended for the diagnosis of bone margins in cases of mandibular osteonecrosis. In this article, we report a case in which a generic violet light was used in order to activate bone fluorescence after the administration of tetracycline derivatives, as an alternative to a specific, more expensive equipment that is commercially available for this purpose. The patient had been using alendronate for osteoporosis, resulting in medication-related osteonecrosis of the jaws. METHODS The treatment protocol includes preoperative administration of doxycycline and the application of a generic violet light during surgery in order to observe the fluorescence of bone in response to excitation through the light emitted by this device. RESULTS With an effective visualization of the limit between healthy and devitalized bone tissue, it was possible to perform the necrotic tissue removal. The lesion regressed from stage 2 to stage 0, with no clinical or radiographic evidence of necrotic bone. CONCLUSIONS These results suggest the feasibility of using a generic violet light source as a low-cost alternative for fluorescence-guided surgery.
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Affiliation(s)
- Caroline Ballardin
- Oral and Maxillofacial Surgery Residency, State University of Londrina, Londrina, Brazil
| | | | - Glaykon Alex Vitti Stabile
- Oral and Maxillofacial Surgery Residency, State University of Londrina, Londrina, Brazil.
- Department of Oral Medicine and Pediatric Dentistry, State University of Londrina, Rodovia Celso Garcia Cid, PR 445 Km 380, Campus Universitário, Londrina, PR, CEP 86.057-970, Brazil.
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Merigo E, Cella L, Oppici A, Cristina Arbasi M, Clini F, Fontana M, Fornaini C. Combined Approach to Treat Medication-Related Osteonecrosis of the Jaws. J Lasers Med Sci 2018; 9:92-100. [PMID: 30026893 DOI: 10.15171/jlms.2018.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: The proper therapeutic plan for medication-related osteonecrosis of the Jaw (MRONJ) is still lacking long-term data up to today. They were several high-technological appliances proposed for the different intervention steps, in addition to tissue repair promoters. The reason for proposing an integrated technique is justified, beyond better compliance of the patients associated to the pain and inflammation reduction and bleeding control, there is also achieving better hard and soft tissues healing. Methods: Patients diagnosed with bisphosphonates-related osteonecrosis of the jaws (BRONJ) at the Odontostomatology and Maxillo-Facial Surgery Unit of the Hospital of Piacenza undergone surgical intervention. The intervention was performed by using different devices: Piezosurgery for removing the necrotic bone tissue and for obtaining the bone specimen essential for histological analysis; Er:YAG laser (2940 nm) to vaporize necrotic hard tissue until reaching the bleeding bone; platelet-rich plasma (PRP) to stimulate hard and soft tissue healing; and finally diode laser (808 nm) to perform a biostimulation of the surgical site. Results: All treated patients demonstrated a good postoperative comfort even without using painkillers, no bleeding, and a fast healing process. Most of the patients (92.85%) reached complete healing with a minimum follow up at 6 months. Histological exams demonstrated a good quality without artifacts. Conclusion: Sequential utilization of different high-technologies devices during all the steps of MRONJ treatment allows to perform a faster and less invasive surgery with a more comfortable postoperative healing process and it may represent a new and original approach for treating this severe adverse event.
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Affiliation(s)
- Elisabetta Merigo
- MICORALIS Laboratory EA7354, Faculty of Dentistry, Université "Côte d'Azur", 24 Avenue des Diables Bleus, 06357 Nice, France.,Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
| | - Luigi Cella
- Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
| | - Aldo Oppici
- Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
| | - Maria Cristina Arbasi
- Immunohematology and Transfusion Medicine "Guglielmo da Saliceto" Hospital - via Taverna, 10 - 29100, Piacenza, Italy
| | - Fabio Clini
- Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
| | - Matteo Fontana
- Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
| | - Carlo Fornaini
- MICORALIS Laboratory EA7354, Faculty of Dentistry, Université "Côte d'Azur", 24 Avenue des Diables Bleus, 06357 Nice, France.,Odontostomatology and Maxillo-Facial Surgery Unit - "Special care dentistry", "Guglielmo da Saliceto" Hospital - Via Taverna, 10 - 29100, Piacenza, Italy
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Kagami H, Inoue M, Kobayashi A, Taguchi A, Li X, Yoshizawa M. Issues with the surgical treatment of antiresorptive agent-related osteonecrosis of the jaws. Oral Dis 2018; 24:52-56. [DOI: 10.1111/odi.12783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Affiliation(s)
- H Kagami
- Department of Oral and Maxillofacial Surgery; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
- Department of General Medicine; IMSUT Hospital; The Institute of Medical Science; The University of Tokyo; Tokyo Japan
| | - M Inoue
- Department of Oral and Maxillofacial Surgery; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
| | - A Kobayashi
- Department of Oral and Maxillofacial Surgery; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
| | - A Taguchi
- Department of Oral and Maxillofacial Radiology; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
| | - X Li
- Department of Oral and Maxillofacial Surgery; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
| | - M Yoshizawa
- Department of Oral and Maxillofacial Surgery; School of Dentistry; Matsumoto Dental University; Shiojiri Japan
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Eleutherakis-Papaiakovou E, Bamias A. Antiresorptive treatment-associated ONJ. Eur J Cancer Care (Engl) 2017; 26. [PMID: 29063702 DOI: 10.1111/ecc.12787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 01/22/2023]
Abstract
Osteonecrosis of the jaw (ONJ) is a severe complication of therapy with antiresorptive agents (e.g. bisphosphonates and denosumab), which are used to manage bone metastases from cancer, to reduce the incidence of skeletal-related events. Available data indicate that 0-27, 5% of patients exposed to antiresorptive agents may develop ONJ, depending on the number of infusions and the duration of therapy. Besides antiresorptive therapy, a number of risk factors for osteonecrosis have been identified. Oral surgical procedures, tooth extractions and infection to the jawbones are considered the main risk factors for developing ONJ, when receiving antiresorptive therapy. However, a growing number of patients develop ONJ without apparent risk factors, raising concern for other predisposing factors. Jaw bone necrosis may be irreversible, resulting in a chronic disease with negative impact on the quality of patients' lives. The role of risk reduction strategies like meticulous dental screening and optimal oral hygiene is fundamental for preventing development of ONJ. ONJ is usually treated conservatively to relieve the symptoms and manage jaw bone necrosis. In certain cases, surgical intervention is required. Future research should emphasize individual predisposition to ONJ, more effective preventive measures and more efficient therapeutic procedures.
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Affiliation(s)
- Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
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TORUL D, BEREKET MC. BISPHOSPHONATE INDUCED OSTEONECROSIS OF THE JAWS AND CURRENT THERAPIES. CUMHURIYET DENTAL JOURNAL 2017. [DOI: 10.7126/cumudj.345953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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de Oliveira CC, Brizeno LAC, de Sousa FB, Mota MRL, Alves APNN. Osteonecrosis of the jaw induced by receptor activator of nuclear factor-kappa B ligand (Denosumab) - Review. Med Oral Patol Oral Cir Bucal 2016; 21:e431-9. [PMID: 26827069 PMCID: PMC4920456 DOI: 10.4317/medoral.21044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 12/09/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Denosumab, an anti-resorptive agent, IgG2 monoclonal antibody for human Receptor activator of nuclear factor-kappa B ligand (RANKL), has been related to the occurrence of osteonecrosis of the jaws. Thus, the aim of this study was to review the literature from clinical case reports, regarding the type of patient and the therapeutic approach used for osteonecrosis of the jaws induced by chronic use of Denosumab. MATERIAL AND METHODS For this, a literature review was performed on PubMed, Medline and Cochrane databases, using the keywords "Denosumab" "anti-RANK ligand" and "Osteonecrosis of jaw". To be included, articles should be a report or a serie of clinical cases, describing patients aged 18 years or over who used denosumab therapy and have received any therapy for ONJ. RESULTS Thirteen complete articles were selected for this review, totaling 17 clinical cases. The majority of ONJ cases, patients receiving Denosumab as treatment for osteoporosis and prostate cancer therapy. In most cases, patients affected by ONJ were women aged 60 or over and posterior mandible area was the main site of involvement. Diabetes pre-treatment with bisphosphonates and exodontia were the most often risk factors related to the occurrence of this condition. Systemic and local antibiotic therapy with or without surgical debridement was the most used treatment for ONJ resolution. CONCLUSIONS It is concluded that the highest number of ONJ cases caused by the use of anti-RANKL agents occurred in female patients, aged 60 years or older, under treatment for osteoporosis and cancer metastasis, and the most affected region was the mandible posterior.
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Affiliation(s)
- C-C de Oliveira
- Division of Oral Pathology, Department of Clinical Dentistry, School of Dentistry, Federal University of Ceará, Alexandre Barauna Street, 949, Rodolfo Teofilo, 60430-160, Fortaleza, Ceará, Brazil,
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Arany PR. Craniofacial Wound Healing with Photobiomodulation Therapy: New Insights and Current Challenges. J Dent Res 2016; 95:977-84. [PMID: 27161014 DOI: 10.1177/0022034516648939] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The fundamental pathophysiologic response for the survival of all organisms is the process of wound healing. Inadequate or lack of healing constitutes the etiopathologic basis of many oral and systemic diseases. Among the numerous efforts to promote wound healing, biophotonics therapies have shown much promise. Advances in photonic technologies and a better understanding of light-tissue interactions, from parallel biophotonics fields such as in vivo optical imaging and optogenetics, are spearheading their popularity in biology and medicine. Use of high-dose lasers and light devices in dermatology, ophthalmology, oncology, and dentistry are now popular for specific clinical applications, such as surgery, skin rejuvenation, ocular and soft tissue recontouring, and antitumor and antimicrobial photodynamic therapy. However, a less well-known clinical application is the therapeutic use of low-dose biophotonics termed photobiomodulation (PBM) therapy, which is aimed at alleviating pain and inflammation, modulating immune responses, and promoting wound healing and tissue regeneration. Despite significant volumes of scientific literature from clinical and laboratory studies noting the phenomenological evidence for this innovative therapy, limited mechanistic insights have prevented rigorous and reproducible PBM clinical protocols. This article briefly reviews current evidence and focuses on gaps in knowledge to identify potential paths forward for clinical translation with PBM therapy with an emphasis on craniofacial wound healing. PBM offers a novel opportunity to examine fundamental nonvisual photobiological processes as well as develop innovative clinical therapies, thereby presenting an opportunity for a paradigm shift from conventional restorative/prosthetic approaches to regenerative modalities in clinical dentistry.
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Affiliation(s)
- P R Arany
- Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, USA
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Efficacy of laser therapy in the management of bisphosphonate-related osteonecrosis of the jaw (BRONJ): a systematic review. Lasers Med Sci 2016; 31:1261-72. [DOI: 10.1007/s10103-016-1929-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
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