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Amin H, Andersen SWM, Jensen SS, Kofod T. Surgical and conservative treatment outcomes of medication-related osteonecrosis of the jaw located at tori: a retrospective study. Oral Maxillofac Surg 2024:10.1007/s10006-024-01214-5. [PMID: 38418702 DOI: 10.1007/s10006-024-01214-5] [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: 03/17/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Tori and exostoses are considered risk factors for the development of medication-related osteonecrosis of the jaw (MRONJ). The aims of this study were to present the prevalence of MRONJ located at tori in the Copenhagen ONJ Cohort, evaluate the surgical treatment of MRONJ located at tori and explore trauma to tori as an additional risk factor in patients on antiresorptive medication. METHODS Data from a consecutive series of 506 patients with MRONJ (Copenhagen ONJ Cohort) were reviewed for the presence of tori and MRONJ located at tori. Demographic and medical data were analyzed, and healing outcomes and pain after the prophylactic removal of tori, surgical treatment of MRONJ located at tori, and conservative treatment of MRONJ located at tori were evaluated and compared using Fisher's exact test. RESULTS MRONJ located at tori was frequent and could be identified in 53% of the patients with tori, which accounts for a prevalence of 5.1% in the entire cohort. Of the 28 surgically treated patients, 27 (96.4%) healed uneventfully with no exposed bone after their first or second revision surgery. Fourteen (41.2%) patients with tori underwent therapeutic removal, eight (23.5%) underwent prophylactic removal, and six (17.6%) underwent both therapeutic and prophylactic removals. Two (33.3%) of the six conservatively treated patients healed spontaneously. Both treatment types resulted in a significant decrease in pain. CONCLUSION Prophylactic and therapeutic surgical removal of tori are reliable treatments and should be considered if a patient's general health allows surgery. TRIAL REGISTRATION The study was approved by the Regional Scientific Ethical Committee (H-6-2013-010) on November 20, 2013, and was retrospectively registered.
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Affiliation(s)
- Hameda Amin
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Simon Storgård Jensen
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark
- Research Area Oral Surgery, Section for Oral Biology and Immunopathology, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Kofod
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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Andersen SWM, Ottesen C, Gotfredsen K, Jensen SS, Kofod T, Schiodt M. Outcome of healing after dental implant placement in patients with cancer on high-dose antiresorptive medications: a prospective feasibility study. Oral Maxillofac Surg 2023; 27:89-100. [PMID: 35084584 DOI: 10.1007/s10006-022-01042-5] [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: 08/17/2021] [Accepted: 01/11/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Implant placement in patients with cancer receiving high-dose antiresorptive medication (HDAR) is considered contraindicated. This prospective, feasibility study tested the hypothesis that dental implants can be placed in such patients by applying a staged implant placement protocol with submerged healing. METHODS Three groups of patients on HDAR were included as follows: group 1: patients who underwent tooth extraction, without the development of medication-related osteonecrosis of the jaws (MRONJ); group 2: patients with surgically treated MRONJ who had demonstrated clinical healing for at least 3 months; group 3: patients with established MRONJ who was planned for surgical resection and simultaneous implant placement. RESULTS A total of 49 implants were placed in 27 patients (group 1: 12, group 2: 7 and group 3: 8). HDAR included bisphosphonates and denosumab. The mean HDAR time was 25 months (SD: ± 18.4, range 3-68 months). An abutment operation was performed 4 months following the implant placement (SD: ± 1.9, range 3-14 months). All patients healed uneventfully. CONCLUSIONS This study demonstrated that it is feasible to insert dental implants and perform an abutment surgery in patients with cancer on HDAR, without the development of MRONJ. CLINICALTRIALS gov Identifier: NCT04741906.
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Affiliation(s)
- Sanne Werner Møller Andersen
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Camilla Ottesen
- Department of Oral Rehabilitation, School of Dentistry, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Alle 20, 2200, Copenhagen N, Denmark
| | - Klaus Gotfredsen
- Department of Oral Rehabilitation, School of Dentistry, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Alle 20, 2200, Copenhagen N, Denmark
| | - Simon Storgård Jensen
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Oral Surgery, School of Dentistry, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Alle 20, 2200, Copenhagen N, Denmark
| | - Thomas Kofod
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Morten Schiodt
- Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
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Aboalela AA, Farook FF, Alqahtani AS, Almousa MA, Alanazi RT, Almohammadi DS. The Effect of Antiresorptive Drug Holidays on Medication-Related Osteonecrosis of the Jaw: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30485. [DOI: 10.7759/cureus.30485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/05/2022] Open
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Teledentistry as a Supportive Tool for Dentists in Diagnosing MRONJ in Northern Cyprus. BIOMED RESEARCH INTERNATIONAL 2022; 2021:5657152. [PMID: 35005018 PMCID: PMC8731282 DOI: 10.1155/2021/5657152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/07/2021] [Indexed: 12/02/2022]
Abstract
Objective This web-based survey, as a tool of teledentistry, is aimed at assessing the level of knowledge, attitudes, and awareness regarding MRONJ among dental professionals in Northern Cyprus. Methods An online self-administered questionnaire about MRONJ was sent to all dentists in Northern Cyprus through Google Forms. The first part of the questionnaire consists of demographic and professional information, and the second part included questions about knowledge and awareness questions about MRONJ. The SPSS software was used for statistical data analysis. A Chi-square test was performed to compare between the groups. The significance level was set at p < 0.05. Results A total of 112 dentists participated in this survey. The participants showed an insufficient level of knowledge regarding MRONJ, as only 56.6% of the participants stated that they had general knowledge about MRONJ. Regarding the practical questions of the survey, the participants showed poor knowledge about implant and tooth extraction procedures while a patient is using antiresorptive or antiangiogenic drugs, particularly the usage of oral antiresorptive or antiangiogenic drugs for less than 3 years. Participants showed adequate knowledge in terms of usage area of medications and administration of them. Conclusion Teledentistry can be used as a supportive tool for dentists in diagnosing MRONJ. Similar to previous studies, the knowledge and awareness of MRONJ of dentists in Northern Cyprus were found to be inadequate. There is a significant need to provide more professional information as part of undergraduate programs so that the next generation of dentists can practice more confidently.
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Risk factors associated with onset of medication-related osteonecrosis of the jaw in patients treated with denosumab. Clin Oral Investig 2021; 26:2839-2852. [PMID: 34812959 PMCID: PMC8898220 DOI: 10.1007/s00784-021-04261-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/23/2021] [Indexed: 12/24/2022]
Abstract
Objectives While risk factors of bisphosphonate (BP) associated osteonecrosis of the jaw have been properly analyzed, studies focusing on risk factors associated with denosumab (DNO) are sparse. The purpose of this study was to identify risk factors influencing the onset of medication-related osteonecrosis of the jaw (MRONJ) in patients receiving antiresorptive treatment (ART) with DNO by comparing patients suffering from MRONJ and patients without MRONJ. Multiple variables were evaluated including the impact of a previous BP intake. Materials and methods A retrospective single-center cohort study with patients receiving DNO was conducted. One-hundred twenty-eight patients were included and divided into three groups: I (control, n = 40) receiving DNO with absence of MRONJ; group II (Test 1, n = 46), receiving DNO with presence of MRONJ; and group III (Test 2, n = 42) sequentially receiving BP and DNO with presence of MRONJ. Patients’ medical history, focusing on the identification of MRONJ risk factors, was collected and evaluated. Parameters were sex, age, smoking habit, alcohol consumption, underlying disease (cancer type, osteoporosis), internal diseases, additional chemo/hormonal therapy, oral inflammation, and trauma. Results The following risk factors were identified to increase MRONJ onset significantly in patients treated with DNO: chemo/hormonal therapy (p = 0.02), DNO dosage (p < 0.01), breast cancer (p = 0.03), intake of corticosteroids (p = 0.04), hypertension (p = 0.02), diabetes mellitus (p = 0.04), periodontal disease (p = 0.03), apical ostitis (p = 0.02), and denture use (p = 0.02). A medication switch did not affect MRONJ development (p = 0.86). Conclusions Malignant diseases, additional chemotherapy, DNO dosage, and oral inflammations as well as diabetes mellitus and hypertension influence MRONJ onset in patients treated with DNO significantly. Clinical relevance Patients receiving ART with DNO featuring aforementioned risk factors have a higher risk of MRONJ onset. These patients need a sound and regular prophylaxis in order to prevent the onset of MRONJ under DNO treatment.
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Ottesen C, Schiodt M, Jensen SS, Kofod T, Gotfredsen K. Tooth extractions in patients with cancer receiving high-dose antiresorptive medication: a randomized clinical feasibility trial of drug holiday versus drug continuation. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:165-173. [PMID: 34275774 DOI: 10.1016/j.oooo.2021.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction to high-dose antiresorptive medication (AR) in patients with cancer. A temporary discontinuation of AR (drug holiday) has been suggested to potentially reduce the risk of MRONJ after oral surgery. However, no consensus exists. The aim of the present feasibility trial was to evaluate the impact of a high-dose AR drug holiday in connection with surgical tooth extraction on the development of MRONJ and patient-reported health state. STUDY DESIGN Patients with cancer receiving high-dose AR were randomized to a drug holiday from 1 month before to 3 months after surgical tooth extraction or drug continuation. Follow-up was scheduled at 1, 3, and 6 months postoperatively. Patient health state was evaluated using the EQ-5D-5L questionnaire. RESULTS The study included 23 patients (11 men, 12 women). AR included denosumab (n = 13) and bisphosphonate (n = 10) with median AR durations of 9 and 17.5 months, respectively. Four denosumab patients from the drug holiday group developed MRONJ. Differences in EQ-5D-5L between the treatment groups were found in favor of drug continuation. CONCLUSIONS The results indicate that a high-dose AR drug holiday does not prevent development of MRONJ after surgical tooth extraction and that patient-reported health state declines during a drug holiday compared with drug continuation.
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Affiliation(s)
- C Ottesen
- Research Area Oral Rehabilitation, Section for Oral Health, Society and Technology, Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Oral & Maxillofacial Surgery, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark.
| | - M Schiodt
- Department of Oral & Maxillofacial Surgery, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S S Jensen
- Department of Oral & Maxillofacial Surgery, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark; Research Area Oral Surgery, Section for Oral Biology and Immunopathology, Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - T Kofod
- Department of Oral & Maxillofacial Surgery, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - K Gotfredsen
- Research Area Oral Rehabilitation, Section for Oral Health, Society and Technology, Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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EKMEKÇİOĞLU A, AKAY G, KARADAĞ Ö, GÜNGÖR K. The Awareness and Knowledge of Dentists about Medication-Related Osteonecrosis of Jaws. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2021. [DOI: 10.33808/clinexphealthsci.701257] [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]
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Efficacy of a high-dose antiresorptive drug holiday to reduce the risk of medication-related osteonecrosis of the jaw (MRONJ): A systematic review. Heliyon 2020; 6:e03795. [PMID: 32373730 PMCID: PMC7191576 DOI: 10.1016/j.heliyon.2020.e03795] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/10/2019] [Accepted: 04/14/2020] [Indexed: 11/21/2022] Open
Abstract
A temporary discontinuation (drug holiday) of high-dose antiresorptive (AR) agents has been proposed to reduce the risk of medication-related osteonecrosis of the jaw (MRONJ). The aim of this systematic review was to answer the question: Is high-dose AR drug holiday, at the time of tooth extraction or dentoalveolar surgery, necessary to prevent the development of MRONJ in patients with cancer? This protocol was registered in the PROSPERO database. Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant studies up to and including April 2019. Randomized controlled trials (RCTs), cohort and cross-sectional studies, surveys, and case reports with more than five patients were included. Records were imported into www.covidence.org. Electronic searches were supplemented by manual searches and reference linkage. The Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) were followed. Although only one study fitted the population, intervention, comparison, outcome (PICO) framework, valuable information on AR drug holiday could be extracted from 14 of 371 reviewed articles. Among these, 3 were prospective and 11 were retrospective studies. These studies described or evaluated high-dose AR drug holidays. In 2 studies, patients were being treated with denosumab, but neither showed that a drug holiday was effective. The remaining 12 studies evaluated bisphosphonate treatment and 2 of these studies found no reason to use AR drug holiday before surgery. Three studies recommended drug holidays, whereas most of the studies recommended assessing each patient separately. The only paper that fitted the PICO approach was a non-randomized, prospective study with a control group. This study concluded that drug holiday was not necessary. Thus, there are no evidence for using drug holiday, but it is also clear that caused by a limited numbers of eligible patients, and a great variation in between these patient, high-level evidence for using AR drug holiday is almost impossible to obtain.
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Nicolatou‐Galitis O, Papadopoulou E, Vardas E, Kouri M, Galiti D, Galitis E, Alexiou K, Tsiklakis K, Ardavanis A, Razis E, Athanasiadis I, Droufakou S, Psyrri A, Karamouzis MV, Linardou H, Daliani D, Tzanninis D, Sachanas S, Laschos K, Kyrtsonis M, Antoniou F, Laskarakis A, Giassas S, Nikolaidi A, Rigakos G, Ntokou A, Migliorati CA, Ripamonti CI. Alveolar bone histological necrosis observed prior to extractions in patients, who received bone‐targeting agents. Oral Dis 2020; 26:955-966. [DOI: 10.1111/odi.13294] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 12/26/2019] [Accepted: 01/28/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Ourania Nicolatou‐Galitis
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Erofili Papadopoulou
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Emmanouil Vardas
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Maria Kouri
- Clinic of Hospital Dentistry Densstal School National & Kapodistrian University of Athens Athens Greece
| | - Dimitra Galiti
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | - Evangelos Galitis
- Clinic of Oral and Maxillofacial Surgery Dental School National & Kapodistrian University of Athens Athens Greece
| | - Konstantina‐Eleni Alexiou
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | - Kostas Tsiklakis
- Clinic of Oral Diagnosis & Radiology Dental School National & Kapodistrian University of Athens Athens Greece
| | | | - Evangelia Razis
- Third Medical Oncology Department Hygeia Hospital Athens Greece
| | | | | | - Amanda Psyrri
- Attikon Hospital National and Kapodistrian University of Athens Athens Greece
| | - Michalis V. Karamouzis
- Department of Biological Chemistry and First Department of Internal Medicine Laikon Hospital, Medical School National and Kapodistrian University of Athens Athens Greece
| | | | - Danai Daliani
- First Medical Oncology Department Euroclinic of Athens Athens Greece
| | | | - Sotirios Sachanas
- Department of Hematology Athens Medical Center Psychikon Branch Athens Greece
| | - Konstantinos Laschos
- 2nd Oncology Department General and Oncologic Hospital “Agii Anargyri” Athens Greece
| | | | - Fotini Antoniou
- Department of Oncology Unit Elena Venizelou Maternity Hospital Athens Greece
| | | | - Styllianos Giassas
- 2nd Oncology Clinic IASO Maternity Hospital and 3rd Oncology Clinic Metropolitan General Hospital Athens Greece
| | | | - George Rigakos
- Third Medical Oncology Department Hygeia Hospital Athens Greece
| | - Anna Ntokou
- Oncology Department Saint Savvas Hospital Athens Greece
| | - Cesar A. Migliorati
- Department of Diagnostic Sciences and Oral Medicine University of Florida Health Science Center College of Dentistry Gainesville FL USA
| | - Carla I. Ripamonti
- Supportive Care Unit Department of Medical Oncology and Haematology Fondazione IRRCS Istituto Nazionale dei Tumori Milano Italy
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Khominsky A, Lim MAWT. “Spontaneous” medication-related osteonecrosis of the jaw; two case reports and a systematic review. Aust Dent J 2018; 63:441-454. [DOI: 10.1111/adj.12648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
- A Khominsky
- Dental Unit; The Alfred Hospital; Prahran Victoria Australia
| | - MAWT Lim
- Dental Unit; The Alfred Hospital; Prahran Victoria Australia
- Melbourne Dental School; Royal Dental Hospital of Melbourne; Carlton Victoria Australia
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Hingst V, Weber MA. Bildgebende Diagnostik bei medikamenteninduzierten Kiefernekrosen. Radiologe 2018; 58:935-948. [DOI: 10.1007/s00117-018-0443-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Otto S, Pautke C, Van den Wyngaert T, Niepel D, Schiødt M. Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases. Cancer Treat Rev 2018; 69:177-187. [PMID: 30055439 DOI: 10.1016/j.ctrv.2018.06.007] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 01/12/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is primarily an adverse side effect of denosumab or bisphosphonates (particularly when used at high doses to prevent skeletal-related events [SREs] in patients with cancer and bone metastases) or possibly anti-angiogenic cancer treatment. While the implementation of preventive measures over recent years has reduced the risk of MRONJ in patients with bone metastases due to cancer, it is imperative to balance the risk of MRONJ against the beneficial effects of treatment with denosumab or bisphosphonates on the skeletal health of patients. Despite growing awareness of MRONJ within the medical community, there is a lack of large-scale, prospective clinical studies in this rapidly evolving field. Discussing preventive measures with patients and implementing them, both before and during treatment with bisphosphonates or denosumab, is the best option to reduce the risk of MRONJ. In particular, avoiding bone trauma and preventing and treating dental infections before and during denosumab or bisphosphonate therapy is crucial to minimize the risk of MRONJ. If MRONJ develops, conservative (non-surgical) treatment can provide symptom relief, but achieving mucosal closure remains challenging. When management of symptoms and mucosal healing are the ultimate goals of therapy, or after failure of conservative treatment, a surgical approach may be beneficial. This critical review, based on a best-evidence review of currently available literature, provides clear practical guidelines to help to prevent, manage and treat MRONJ. Overall, a multidisciplinary, pragmatic approach to MRONJ should be adopted, prioritizing patient's quality of life and management of their skeletal malignant disease.
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium; Molecular Imaging Center Antwerp, University of Antwerp, Antwerp, Belgium.
| | | | - Morten Schiødt
- Department of Oral and Maxillofacial Surgery, Rigshospitalet, Copenhagen, Denmark.
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Lorenzo-Pouso AI, Pérez-Sayáns M, García A, Carballo J. Vitamin D supplementation: Hypothetical effect on medication-related osteonecrosis of the jaw. Med Hypotheses 2018; 116:79-83. [PMID: 29857915 DOI: 10.1016/j.mehy.2018.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/10/2018] [Accepted: 04/27/2018] [Indexed: 10/17/2022]
Abstract
Vitamin D is an important nutrient for bone health and skeleton growth. Few foods are natural sources of this secosteroid; this is the reason why the consumption of vitamin D as a dietary supplement is becoming common in developed countries. For many years vitamin D has been considered crucial in the treatment and prevention of the Global Burden of Disease and in a reduction in mortality among elder people. Many health care providers prescribe these supplements in the management of osteoporosis and metabolic bone diseases; specifically in the primary prevention of fractures. Recently medication-related osteonecrosis of the jaw (MRONJ) has been reported as severe late sequelae of antiresorptive therapies (i.e., bisphosphonates and some monoclonal antibodies). Although MRONJ-related pathophysiology is not fully understood, there are three fundamental theories to explain it: (1) the inhibition of osteoclasts, (2) the inhibition of angiogenesis and (3) the processes of inflammation-infection. Recent advances in Vitamin D research have shown that this secosteroid can play a potential pivotal role in many of the different etiological pathways of MRONJ. Furthermore, there are a large number of co-morbidities between the deficit of this vitamin and other MRONJ concomitant outcomes. Our hypothesis argues that the low-risk and low-cost vitamin D dietary supplementation may prove to be suitable for use as a practical MRONJ prevention strategy. The described framework gives more insight into the study of disease mechanisms, search of potential biomarkers, and therapeutic targets in MRONJ.
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Affiliation(s)
- Alejandro I Lorenzo-Pouso
- Oral Medicine, Oral Surgery and Implantology Unit, School of Dentistry, Faculty of Medicine and Odontology, University of Santiago de Compostela, Santiago de Compostela, Spain; GI-1319 Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - Mario Pérez-Sayáns
- Oral Medicine, Oral Surgery and Implantology Unit, School of Dentistry, Faculty of Medicine and Odontology, University of Santiago de Compostela, Santiago de Compostela, Spain; GI-1319 Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Abel García
- Oral Medicine, Oral Surgery and Implantology Unit, School of Dentistry, Faculty of Medicine and Odontology, University of Santiago de Compostela, Santiago de Compostela, Spain; GI-1319 Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Javier Carballo
- Department of Food Technology, Faculty of Sciences, University of Vigo - Ourense Campus, Ourense, Spain
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Schiodt M, Vadhan-Raj S, Chambers MS, Nicolatou-Galitis O, Politis C, Coropciuc R, Fedele S, Jandial D, Zhang J, Ma H, Saunders DP. A multicenter case registry study on medication-related osteonecrosis of the jaw in patients with advanced cancer. Support Care Cancer 2017; 26:1905-1915. [PMID: 29275525 PMCID: PMC5919994 DOI: 10.1007/s00520-017-4003-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 12/03/2017] [Indexed: 11/28/2022]
Abstract
Purpose This observational case registry study was designed to describe the natural history of cancer patients with medication-related osteonecrosis of the jaw (ONJ) and evaluate the ONJ resolution rate. Methods Adults with a diagnosis of cancer and with a new diagnosis of ONJ were enrolled and evaluated by a dental specialist at baseline and every 3 months for 2 years and then every 6 months for 3 years until death, consent withdrawal, or loss to follow-up. The primary endpoint was the rate and time course of ONJ resolution. Secondary endpoints included frequency of incident ONJ risk factors, ONJ treatment patterns, and treatment patterns of antiresorptive agents for subsequent ONJ. Results Overall, 327 patients were enrolled; 207 (63%) were continuing on study at data cutoff. Up to 69% of evaluable patients with ONJ had resolution or improvement during the study. ONJ resolution (AAOMS ONJ staging criteria) was observed in 114 patients (35%); median (interquartile range) time from ONJ onset to resolution was 7.3 (4.5–11.4) months. Most patients (97%) had received antiresorptive medication before ONJ development, 9 patients (3%) had not; 68% had received zoledronic acid, 38% had received denosumab, and 10% had received pamidronate (56% had received bisphosphonates only, 18% had received denosumab only, and 21% had exposure to both). Conclusions These results are consistent with those observed in clinical trials evaluating skeletal-related events in patients with advanced malignancy involving bone. Longer follow-up will provide further information on ONJ recurrence and resolution rates between medically and surgically managed patients.
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Affiliation(s)
- Morten Schiodt
- Department of Oral and Maxillofacial Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ruxandra Coropciuc
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Stefano Fedele
- University College of London Eastman Dental Institute and National Institutes for Research Health, University College of London Hospitals Biomedical Research Center, London, UK
| | | | | | | | - Deborah P Saunders
- Department of Dental Oncology, Health Sciences North, Northeast Cancer Centre, Northern Ontario School of Medicine, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.
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Abel Mahedi Mohamed H, Nielsen CEN, Schiodt M. Medication related osteonecrosis of the jaws associated with targeted therapy as monotherapy and in combination with antiresorptives. A report of 7 cases from the Copenhagen Cohort. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 125:157-163. [PMID: 29221983 DOI: 10.1016/j.oooo.2017.10.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/24/2017] [Accepted: 10/27/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of this study was to report cases of medication-related osteonecrosis of the jaws (MRONJ) associated with targeted therapy (TT) with or without concomitant antiresorptive treatment, among the Copenhagen ONJ cohort, which includes all consecutive cases of MRONJ seen in Copenhagen. STUDY DESIGN We retrospectively studied the treatment of 204 consecutive patients with MRONJ, seen between January 2010 and May 2016, to identify those associated with TT. RESULTS We detected 7 cases of MRONJ associated with TT (3.4%). Four patients received TT only, whereas 3 were concomitantly treated with bisphosphonates (n = 3) and/or denosumab (n = 3). The TT regimens included sunitinib (Sutent) (n = 1), everolimus (Afinitor) (n = 1), erlotinib (Tarceva) (n = 1), bevacizumab (Avastin) (n = 3), dasatinib (Sprycel) (n = 1) and imatinib (Glivec) (n = 1). The MRONJ stage included stages 1 and 2, and mean score on the visual analogue scale for pain in the jaw was 4.0. CONCLUSIONS Health care providers should be aware of the possibility of MRONJ associated with the TT agents sunitinib, everolimus, and dasatinib and uncommon cancer types, including renal cell carcinoma, non-small-cell lung cancer, glioblastoma, and leukemia, where MRONJ may also occur.
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Affiliation(s)
- Hoda Abel Mahedi Mohamed
- Department of Oral & Maxillofacial Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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16
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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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17
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Eiken PA, Prieto-Alhambra D, Eastell R, Abrahamsen B. Surgically treated osteonecrosis and osteomyelitis of the jaw and oral cavity in patients highly adherent to alendronate treatment: a nationwide user-only cohort study including over 60,000 alendronate users. Osteoporos Int 2017; 28:2921-2928. [PMID: 28664276 DOI: 10.1007/s00198-017-4132-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Osteonecrosis of the jaw (ONJ) is rare (2.53/10,000 person-years) among alendronate users, but long-term and compliant use are associated with an increased risk of surgically treated ONJ. Risk of surgically treated ONJ is higher in patients with rheumatoid diseases and use of proton pump inhibitors. INTRODUCTION ONJ is a rare event in users of oral bisphosphonates. Our aims were to evaluate if the risk of surgically treated ONJ increases with longer or more compliant treatment with alendronate for osteoporosis and to identify risk factors for surgically treated ONJ. METHODS Open nationwide register-based cohort study containing one nested case-control study. Patients were treatment-naïve incident users of alendronate 1996-2007 in Denmark, both genders, aged 50-94 at the time of beginning treatment (N = 61,990). Participants were followed to 31 December 2013. RESULTS Over a mean of 6.8 years, 107 patients received surgery for ONJ or related conditions corresponding to an incidence rate of 2.53 (95% confidence interval (CI) 2.08 to 3.05) per 10,000 patient years. Recent use was associated with an adjusted odds ratio (OR) 4.13 (95% CI 1.94 to 8.79) compared to past use. Similarly, adherent users (medication possession ratio (MPR) >50%) were at two to threefold increased risk of ONJ compared to low adherence (MPR <50%), and long-term (>5 years) use was related with higher risk (adjusted OR 2.31 (95% CI (1.14 to 4.67)) than shorter-term use. History of rheumatoid disorders and use of proton pump inhibitors were independently associated with surgically treated ONJ. CONCLUSIONS Our data suggest that recent, long-term, and compliant uses of alendronate are associated with an increased risk of surgically treated ONJ. Nevertheless, the rates remain low, even in long-term adherent users. ONJ risk appears higher in patients with conditions likely to indirectly affect the oral mucosa.
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Affiliation(s)
- P A Eiken
- Department of Cardiology, Nephrology and Endocrinology, North Zealand Hospital, Hillerød, Dyrehavevej 29, 3400, Hillerød, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
| | - D Prieto-Alhambra
- Musculoskeletal Pharmaco and Device Epidemiology, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
- GREMPAL Research Group and CIBERFes, Idiap Jordi Gol, Universitat Autònoma de Barcelona and Instituto Carlos III (FEDER Research Funds), Av Gran Via Corts Catalanes 185, 08003, Barcelona, Spain
| | - R Eastell
- Academic Unit of Bone Metabolism (AUBM), University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
| | - B Abrahamsen
- Department of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, J.B. Winsløws Vej 9 A, 3. Sal, 5000, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
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18
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Otto S, Pautke C, Martin Jurado O, Nehrbass D, Stoddart MJ, Ehrenfeld M, Zeiter S. Further development of the MRONJ minipig large animal model. J Craniomaxillofac Surg 2017; 45:1503-1514. [PMID: 28803745 DOI: 10.1016/j.jcms.2017.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 01/11/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious and potentially severe side effect of antiresorptive therapy with bisphosphonates or denosumab. Recently, a large animal minipig MRONJ model was introduced which led to early necrotic lesions in the majority of extraction sites after bisphosphonate administration. The aim of this project was to modify the preoperative cumulative bisphosphonate dose (zoledronate) and hereby firstly to demonstrate the reliability and reproducibility of the established model. Secondly, the MRONJ lesions should be carefully investigated using clinical and μCT as well as detailed histological analyses. Twelve 1.5-year-old Göttingen minipigs were divided into three groups. In group 1 (n = 3) minipigs received weekly doses of zoledronate intravenously (0.05 mg/kg bodyweight) for 20 weeks. No interventions were performed. In group 2 (n = 6) animals received the identical zoledronate dosage as animals in group 1 and tooth extractions of two premolars (PM 2 and 4) in each jaw (maxilla and mandible) were performed after 12 weeks. Group 3 (n = 3) served as tooth extraction only control (no zoledronate administrations). The jaw-bones were subjected to detailed macroscopic, radiological and histological investigations. All extraction sites (24/24) in animals of group 2 showed clinical, radiological and histological signs of MRONJ (mainly stage II), whereas no bone necrosis was found in group 3. Animals of group 1 and group 2 showed further MRONJ lesions in areas where infections (periodontitis) were present. This is the first large animal model to show a 100% incidence of MRONJ at all extraction sites in bisphosphonate pretreated animals (group 2). In addition, in this preclinical model for MRONJ it is shown that tooth extractions are not mandatory for a MRONJ manifestation. MRONJ also developed in areas of gingival or periodontal infections.
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Affiliation(s)
- Sven Otto
- Ludwig-Maximilians University of Munich, Department of Oral and Maxillofacial Surgery (Chair: Prof. Dr. Dr. M. Ehrenfeld), Lindwurmstr. 2a, D-80336 Munich, Germany.
| | - Christoph Pautke
- Ludwig-Maximilians University of Munich, Department of Oral and Maxillofacial Surgery (Chair: Prof. Dr. Dr. M. Ehrenfeld), Lindwurmstr. 2a, D-80336 Munich, Germany; Medizin & Aesthetik, Clinic for Oral and Maxillofacial and Plastic Surgery, Lenbachplatz 2a, D-80333 Munich, Germany
| | | | - Dirk Nehrbass
- AO Research Institute Davos, Clavadelerstr. 8, 7270, Davos, Switzerland
| | - Martin J Stoddart
- AO Research Institute Davos, Clavadelerstr. 8, 7270, Davos, Switzerland; Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Michael Ehrenfeld
- Ludwig-Maximilians University of Munich, Department of Oral and Maxillofacial Surgery (Chair: Prof. Dr. Dr. M. Ehrenfeld), Lindwurmstr. 2a, D-80336 Munich, Germany
| | - Stephan Zeiter
- AO Research Institute Davos, Clavadelerstr. 8, 7270, Davos, Switzerland
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19
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Hallmer F, Bjørnland T, Andersson G, Becktor JP, Kristoffersen AK, Enersen M. Bacterial diversity in medication-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 123:436-444. [PMID: 28159588 DOI: 10.1016/j.oooo.2016.11.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/17/2016] [Accepted: 11/25/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim was to study the association between microflora and medication-related osteonecrosis of the jaw (MRONJ) by using culture-independent molecular techniques to detect bacteria in necrotic bone lesions. STUDY DESIGN Included were 18 consecutive patients with MRONJ, 10 with osteoporosis and 8 cancer patients. Bone biopsies were retrieved from the center of the necrotic bone and from visually healthy bone, and 16 S rRNA gene fragments from bacterial DNA were amplified with polymerase chain reaction. RESULTS The study revealed a diversity of bacteria represented by 16 S rRNA sequences in all the necrotic bone samples and in 60% of the visually healthy bone. Eight dominating taxa groups were identified at the genus level: Porphyromonas, Lactobacillus, Tannerella, Prevotella, Actinomyces, Treponema, Streptococcus, and Fusobacterium. CONCLUSIONS The necrotic bone lesions contained mainly anaerobic bacteria, representative of periodontal microflora, suggesting that a periodontal infection in combination with antiresorptive treatment could initiate osteonecrosis.
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Affiliation(s)
- Fredrik Hallmer
- Consultant, Department of Oral and Maxillofacial Surgery, Skåne University Hospital, Lund, Sweden; Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden.
| | - Tore Bjørnland
- Professor and Chairman, Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Gunilla Andersson
- Associate Professor, Department of Oral and Maxillofacial Surgery, Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Jonas P Becktor
- Associate Professor and Head, Department of Oral and Maxillofacial Surgery Malmö University, Faculty of Odontology, Malmö, Sweden
| | - Anne K Kristoffersen
- Senior Engineer, Department of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Morten Enersen
- Associate Professor, Department of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
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20
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Ceponis P, Keilman C, Guerry C, Freiberger JJ. Hyperbaric oxygen therapy and osteonecrosis. Oral Dis 2016; 23:141-151. [PMID: 27062390 DOI: 10.1111/odi.12489] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/24/2016] [Indexed: 12/18/2022]
Abstract
Osteonecrosis of the jaw may be caused by radiation, medication, or infection. Optimal therapy requires a multimodal approach that combines surgery with adjuvant treatments. This review focuses on the use of adjunctive hyperbaric oxygen therapy for this condition. In addition to evidence regarding the basic and clinical science behind hyperbaric oxygen therapy, controversies in the field and economic implications are discussed.
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Affiliation(s)
- P Ceponis
- Hyperbaric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, ON, Canada
| | - C Keilman
- Hyperbaric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - C Guerry
- Hyperbaric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - J J Freiberger
- Hyperbaric Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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21
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Bejhed RS, Kharazmi M, Hallberg P. Identification of Risk Factors for Bisphosphonate-Associated Atypical Femoral Fractures and Osteonecrosis of the Jaw in a Pharmacovigilance Database. Ann Pharmacother 2016; 50:616-24. [PMID: 27179251 DOI: 10.1177/1060028016649368] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Atypical femoral fractures (AFs) and osteonecrosis of the jaw (ONJ) are well-known adverse drug reactions (ADRs) associated with bisphosphonates. To prevent these ADRs and to aid in the search for pathogenic mechanisms, knowledge of risk factors can be helpful. OBJECTIVE To identify risk factors for bisphosphonate-related ONJ and AF. METHODS In this case-control study of reports of bisphosphonate-related ADRs from February 16, 1984, to October 16, 2013, in the Swedish national database of ADRs, we compared characteristics for cases of ONJ (n = 167) and AF (n = 55) with all other bisphosphonate-related ADRs (n = 565) with regard to demographic variables, clinical characteristics, and concomitant drug treatments. We adjusted for multiple comparisons with Bonferroni correction. RESULTS Time to onset of ADRs differed statistically significantly between cases of AF and controls (2156 vs 111 days). For ONJ versus controls, differences were statistically significant for time to onset (1240 vs 111 days), intravenous administration (40% vs 20%), dental procedures (49% vs 0.2%) and prostheses (5% vs 0%), cancer disease (44% vs 12%), multiple myeloma (21% vs 1%), rheumatoid arthritis (14% vs 5%), and treatment with antineoplastic agents and oxycodone. CONCLUSION These results lend further evidence to previously identified risk factors for ONJ-that is, intravenous bisphosphonate administration; invasive dental procedures and dental prostheses; cancer disease, in particular multiple myeloma; and possibly, long-term bisphosphonate treatment. A putative further risk factor is rheumatoid arthritis. Only long-term bisphosphonate treatment was more common among AF cases. The lack of overlap of risk factors between ONJ and AF suggests different pathogenic mechanisms.
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Affiliation(s)
| | - Mohammad Kharazmi
- Uppsala University, Department of Surgical Sciences, Uppsala, Sweden Central Hospital, Västerås, Sweden
| | - Pär Hallberg
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
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22
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Nicolatou-Galitis O, Razis E, Galiti D, Galitis E, Labropoulos S, Tsimpidakis A, Sgouros J, Karampeazis A, Migliorati C. Periodontal disease preceding osteonecrosis of the jaw (ONJ) in cancer patients receiving antiresorptives alone or combined with targeted therapies: report of 5 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:699-706. [DOI: 10.1016/j.oooo.2015.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/31/2015] [Accepted: 08/10/2015] [Indexed: 01/01/2023]
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