Evaluation of a surgical treatment of denosumab-related osteonecrosis of the jaws

Sixty-Month Follow Up of Clinical MRONJ Cases Treated with CGF and Piezosurgery

AIMS

Medication-related osteonecrosis of the jaw (MRONJ) is a drug-related adverse reaction characterized by bone destruction and necrosis in the jaw. This case series aims to evaluate the treatment approaches and outcomes in MRONJ patients.

MATERIALS AND METHODS

The retrospective study was conducted at the Dental Unit of the University of Bari, Italy. Patients with MRONJ were treated and followed up for 60 months. The treatment approach involved piezosurgery and concentrated growth factor (CGF). Six clinical cases from this group are described in detail.

RESULTS

None of the patients showed recurrence of necrotic MRONJ lesions during the follow-up period. The surgical interventions, including bone resections and the application of CGF, resulted in successful mucosal healing and the prevention of disease progression.

CONCLUSIONS

This study highlights the complexity of managing MRONJ and the importance of a multidisciplinary approach. Conservative treatment options and minimally invasive surgery have shown efficacy in controlling symptoms and improving patients' quality of life. However, the optimal treatment approach remains a challenge, and further studies are needed to evaluate alternative therapies and resective surgery. A comprehensive preoperative evaluation and collaboration among dental, endocrinology, and oncology specialists are crucial for personalized and multidisciplinary management. Ongoing research efforts are necessary to explore new therapeutic modalities and improve our understanding of MRONJ management, providing better support to patients dealing with this complex condition.

Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations

Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.

Tips and Tricks and Clinical Outcome of Cryopreserved Human Amniotic Membrane Application for the Management of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Pilot Study

Medication-related osteonecrosis of the jaw (MRONJ) is a complication of certain pharmacological treatments such as bisphosphonates, denosumab, and angiogenesis inhibitors. There are currently no guidelines on its management, particularly in advanced stages. The human amniotic membrane (hAM) has low immunogenicity and exerts anti-inflammatory, antifibrotic, antimicrobial, antiviral, and analgesic effects. It is a source of stem cells and growth factors promoting tissue regeneration. hAM acts as an anatomical barrier with suitable mechanical properties (permeability, stability, elasticity, flexibility, and resorbability) to prevent the proliferation of fibrous tissue and promote early neovascularization at the surgical site. In oral surgery, hAM stimulates healing and facilitates the proliferation and differentiation of epithelial cells in the oral mucosa and therefore its regeneration. We proposed using cryopreserved hAM to eight patients suffering from cancer (11 lesions) with stage 2–3 MRONJ on a compassionate use basis. A collagen sponge was added in some cases to facilitate hAM grafting. One or three hAMs were applied and one patient had a reapplication. Three patients had complete closure of the surgical site with proper epithelialization at 2 weeks, and two of them maintained it until the last follow-up. At 1 week after surgery, three patients had partial wound dehiscence with partial healing 3 months later and two patients had complete wound dehiscence. hAM reapplication led to complete healing. All patients remained asymptomatic with excellent immediate significant pain relief, no infections, and a truly positive impact on the patients’ quality of life. No adverse events occurred. At 6 months of follow-up, 80% of lesions had complete or partial wound healing (30 and 50%, respectively), while 62.5% of patients were in stage 3. Radiological evaluations found that 85.7% of patients had stable bone lesions (n = 5) or new bone formation (n = 1). One patient had a worsening MRONJ but remained asymptomatic. One patient did not attend his follow-up radiological examination. For the first time, this prospective pilot study extensively illustrates both the handling and surgical application of hAM in MRONJ, its possible association with a collagen sponge scaffold, its outcome at the site, the application of multiple hAM patches at the same time, and its reapplication.

Tocilizumab: Another medication related to osteonecrosis of the jaws? A case report and literature review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive medication, such as bisphosphonates and denosumab, for different oncologic and non-oncologic diseases. Here, we report a case of MRONJ in a patient treated with tocilizumab, a humanized anti-interleukin-6 receptor antibody that effectively treats moderate to severe rheumatoid arthritis in adults.

Case description: A 45-year-old female patient diagnosed with severe rheumatoid arthritis, who had been undergoing intravenous tocilizumab therapy for three years without history of bisphosphonate use, was referred to our department. Four weeks previously, several teeth in the maxilla and mandible were removed under local anesthesia by her dentist. Two weeks after the extractions, she felt pain in both jaws. We diagnosed wound dehiscence and delayed healing of the alveolar bone after the tooth extractions. Digital volume tomography showed persistent dry alveolar sockets. The patient underwent surgical debridement of necrotic bone, and intravenous antibiotics were administered in hospital. Five months later, wound dehiscence reoccurred in the same regions. Histopathological analysis of bone biopsies revealed a diagnosis of MRONJ. Four months later, wound dehiscence occurred in the left maxillary alveolar ridge, and local bone resection was performed under antibiotic treatment. Twenty-four months after the last surgery, wound dehiscence had healed completely without signs of recurrence.

Discussion: Osteomyelitis of the jaw in patients treated with tocilizumab has not been reported often. This case confirms the potential role of this interleukin-6 receptor inhibitor in the pathogenesis of MRONJ and shows that patients who receive tocilizumab with MRONJ-like symptoms should be closely monitored. The pathomechanism of MRONJ under tocilizumab therapy remains unclear, so dental practitioners, maxillofacial surgeons, and rheumatologists should look for signs of MRONJ in patients receiving tocilizumab to prevent MRONJ onset.

The effect of concentrated growth factor (CGF) in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: a randomized controlled study

OBJECTIVES

The purpose of this present study was to evaluate the efficiency of the growth factors delivered by concentrated growth factor (CGF) on the healing process of osteoporotic patients with medication-related osteonecrosis of the jaws (MRONJ).

METHODS

This randomized controlled study was composed of osteoporotic female patients who were treated with oral bisphosphonates (BPs) and diagnosed with MRONJ. For the CGF group, each patient was treated with a local application of CGF at the surgical site after removing the necrotic bone, while the surgical area was primarily closed as traditional surgical therapy for the control group. The patients underwent clinical examinations for 6 months postoperatively to check the presence of infection and dehiscence.

RESULTS

Complete healing was achieved in 19 patients of 28 patients (mean age: CGF group, 73.57 ± 5.1; control group, 73.64 ± 5.49) diagnosed with MRONJ. There was no significant difference in post-op healing data between groups during healing periods (p > 0.05). In the CGF group (n = 14) in three cases, bone exposure without infection was detected, and one of them showed a recurrent infection. In the control group (n = 14) in six cases, bone exposure without infection was detected, and three of them also showed recurrent infection.

CONCLUSION

Although our results were not statistically significant, our findings suggest that the local application of CGF appears to be an effective approach to the surgical treatment of MRONJ in osteoporosis patients by improving tissue regeneration.

CLINICAL RELEVANCE

A specific treatment protocol to manage MRONJ is still controversial. This study justifies that CGF can be used in combination with surgical treatment.

Dental implants as risk factors for patients with medication-related osteonecrosis of the jaws (MRONJ)

An increasing number of patients with medication-related osteonecrosis of the jaws (MRONJ) has recently been reported. It is still being debated whether the presence or placement of dental implants can lead to MRONJ, so the aim of this study was to find out whether dental implants are a risk factor for MRONJ. From January 2003-January 2019 180 patients with MRONJ were seen at the Leiden University Medical Center. Luxating moments for the onset of MRONJ were calculated retrospectively. We collected clinical data and details of antiresorptive medication and found 22 patients with both dental implants and MRONJ. In 18 patients the implants were in the region of the MRONJ and they were included in this study, 14 who had had implants before using antiresorptive drugs and four who had had antiresorptive drugs before or at the time that the implants were placed. The median times between the placement of implants and the diagnosis of MRONJ in these two groups were 24 months and 6 months, respectively. Among the 47 implants, 30 were located in the necrotic region, and all 30 were either lost spontaneously or had to be removed during treatment of MRONJ. Our results show an increased risk for developing MRONJ in patients with dental implants. Both peri-implantitis around previously placed implants, and insertion of dental implants, are risk factors. Prevention of peri-implantitis and caution when inserting dental implants in patients who take antiresorptive medication are therefore important.

Oral Surgical Management of Bone and Soft Tissues in MRONJ Treatment: A Decisional Tree

Background: The aim of the present work was to analyze a 10-year retrospective series of surgically treated medication-related osteonecrosis of the jaws (MRONJ) cases, reporting the clinical outcome and success rate for each adopted procedure in order to draw a treatment algorithm that is able to standardize clinical decision making and maximize the success of oral surgical treatment of MRONJ. Methods: Different surgical approaches were categorized taking into consideration two variables (a) hard tissue management (defined as debridement, saucerization or marginal resective surgery of maxillary necrotic bone) and (b) soft tissue management (defined as type of flap design and related modality of wound-healing). Results: For the retrospective cohort study, 103 MRONJ patients were enrolled and a total of 128 surgical procedures were performed. The role of radical-intended surgery using local flaps in MRONJ treatment was investigated, as well as palliative treatments. All stage I–II patients completely healed when a combination of radical necrotic bone surgery associated with a first intention healing of soft tissues was obtained. In stage III, when a patient was not eligible for maxillo-facial surgery, the use of palliative surgical strategies was effective in symptom relief in order to maintain a better quality of life for the duration of the patient’s life. Conclusions: Oral surgery with radical intent associated with a flap design able to ensure first intention healing might represent a valid option for the majority of MRONJ patients. The designed decision tree allows clinicians to assess individual surgical approaches for MRONJ treatment in accordance with patient-centered outcomes and surgical skills.

Incidence of and risk factors for medication-related osteonecrosis of the jaw in women with breast cancer with bone metastasis: a population-based study

OBJECTIVE

The aim of this study was to prospectively determine the incidence of medication-related osteonecrosis of the jaw (MRONJ) and define risk factors in patients with metastatic breast cancer treated with zoledronic acid and/or denosumab.

STUDY DESIGN

In a prospective cohort study performed in Region Skåne, Sweden, from January 1, 2012, until December 31, 2015, all patients with breast cancer who had radiographic evidence of bone metastases and were treated with zoledronic acid or denosumab were included and followed up until May 31, 2018.

RESULTS

Of the 242 patients, MRONJ developed in 16 (6.6%) during the 77 months of study. The incidence of MRONJ in patients treated with zoledronic acid was 4.1%, and in patients treated with denosumab, it was 13.6%. The risk of MRONJ was higher in patients on denosumab than in those treated with zoledronic acid (P = .011). Corticosteroid use was associated with a decreased risk of MRONJ (P = .008), and diabetes was associated with an increased risk of MRONJ (P = .02).

CONCLUSIONS

The incidence of MRONJ is 13.6% (>3 times higher) in denosumab-treated patients with breast cancer compared with that in patients treated with zoledronic acid (4.1%). Corticosteroid use decreased the risk of MRONJ.

Prevalence, initiating factor, and treatment outcome of medication-related osteonecrosis of the jaw-a 4-year prospective study

OBJECTIVES

Medication-related osteonecrosis of the jaw (MRONJ) has a wide range of prevalence, and a standard therapy has not yet been established. The aim of this study was to analyze the prevalence and initiating factors of MRONJ and the outcomes of surgical therapy.

STUDY DESIGN

In a prospective cohort study, all patients diagnosed with MRONJ in the Region of Skåne, in Sweden, were included. Predictor variables (comorbidity, site, stage, gender) and initiating factors (tooth extraction, periodontitis) were recorded. Surgical treatment was sequestrectomy or block resection, and the outcome variable was healing after 2 months. To estimate the prevalence, data on the use of bisphosphonate and denosumab were used.

RESULTS

Fifty-five patients with MRONJ were identified. The prevalence of MRONJ was 0.043% among patients treated with oral bisphosphonates, 1.03% among those on intravenous bisphosphonates and 3.64% in those on high-dose denosumab. Periodontal disease preceded development of MRONJ in 41 patients. Fifty patients were treated surgically and followed up for at least 2 months. Remission or healing occurred in 80% of patients treated with sequestrectomy and in 92.5% of patients treated with block resection.

CONCLUSIONS

The prevalence of MRONJ in Sweden is low. Periodontitis is the most common initiating factor. The outcome of treatment of MRONJ is healing in most patients treated surgically.

Osteonecrosis of the jaw in patients transitioning from bisphosphonates to denosumab treatment for osteoporosis

Antiresorptive-related osteonecrosis of the jaw (ARONJ) is a rare but severe side effect of antiresorptive treatment with bisphosphonates or RANKL-antibody denosumab in patients with malignant diseases or osteoporosis. Whilst osteonecrosis of the jaw (ONJ) related to the administration of bisphosphonates (BPs) has been investigated for more than 1 decade now, only few data are available on denosumab-related ONJ, especially in patients with osteoporosis. From 2008 to 2016, 52 osteoporosis patients were treated with ARONJ in the Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Germany. In all patients, a surgical regimen consisting of complete removal of necrotic bone, primary wound closure and perioperative i.v. antibiotic therapy was applied. Of the 52 patients, 38 developed ARONJ after BP monotherapy; in 11 patients, antiresorptive therapy had been transitioned from BPs to denosumab and 3 patients had received denosumab monotherapy. From July 2013, when the first patient with ONJ and transitioning therapy from BPs to denosumab presented to our department, to October 2016, we found recurrences in 17.6% of the patients with BP monotherapy and in 45.5% of the patients with transitioning therapy from BPs to denosumab. Transitioning antiresorptive therapy from BPs to denosumab may be an additional risk factor for developing ARONJ. In these patients, treatment of ARONJ-lesions seems to provoke more complications. An additional dental screening before transitioning should be initiated. Further studies are needed to evaluate if a first-line treatment with denosumab decreases the incidence of ARONJ in patients with osteoporosis and simplifies its treatment.

[Evaluation of healing time of osteochemonecrosis of the jaw after surgery: Single-center retrospective study and review of the literature]

INTRODUCTION

Osteochemonecrosis of the jaw (ONJ) is a chronic ischemic bone exposure. It has an increasing incidence. ONJ is mainly related to bisphosphonate and denosumab therapies in oncologic settings. Healing is considered uncertain ad as occurring slowly. International recommendations suggest to treat ONJ symptomatically in a first attempt. A surgical procedure, potentially aggressive, should be carefully weight up in patients in poor condition and whose life expectancy is often limited. However, surgical treatment seems to allow for a high rate of clinical remission. Postoperative remission periods, when mentioned in the studies, are disparate. The aim of our study was to clarify the remission period of ONJ after surgical management.

METHOD

A retrospective study was conducted on all patients operated for an ONJ at stage 2 and 3 in the Department for Oral and Maxillofacial Surgery - University Hospital of Besançon (France) from January 2006 to September 2015. Healing was defined as complete mucosal closure and asymptomatic site. Stage of the disease, the number and the type of surgery and the time between the last operation and the healing was noticed. These data were compared to an exhaustive review of the literature on PubMed with the following key-words: "osteonecrosis" AND "jaw" AND "surgery" AND "management". Only the articles giving the healing period were included.

RESULTS

Regarding the single-center retrospective study, the files of 23 patients could be included. Fifteen percent of the patients benefited from several procedures under general anesthesia. Twenty percent had a stage 3 ONJ and 80 % had a stage 2 ONJ. Twenty-five interventions were performed on 23 sites in 20 patients. Immediate healing after surgery occurred in 35 % of the patients. At 6 months after surgery, 57 % of the treated areas were healed. Twenty percent of the patients had died. The healing rate did not improve further after 6 months postoperatively. Regarding the review of the literature, 7 articles could be included. The mean postoperative healing period was 60.7 % at 6 months, 71.1 % at 12 months and 69.5 % at 18 months.

DISCUSSION

Our study shows that the postoperative healing rate of ONJ lies between 57 and 66.7 % at 6 months and that this rate was optimized in the order of 10 % to 12months and stable at 18months postoperatively. The ONJ of our series were partially or fully linked to other drugs than bisphosphonates in 70 % of the cases: 50 % were related to denosumab, alone or in combination and 35 % were related to an association with antiangiogenics, bevacizumab mainly.

Denosumab: targeting the RANKL pathway to treat rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disorder characterized by focal pathologic bone resorption due to excessive activity of osteoclasts (OC). Receptor activator of nuclear factor kappa B ligand (RANKL) is essential for the proliferation, differentiation, and survival of OC. Denosumab (DMab) is a humanized monoclonal antibody that binds to RANKL with high affinity and blocks its subsequent association with its receptor RANK on the surface of OC precursors. Area covered: The authors review the molecular and cellular mechanisms underlying therapeutic applications of DMab, provide recent highlights on pharmacology, efficacy and safety of DMab, and discuss the potential of DMab as a novel therapeutic option for the treatment of rheumatoid arthritis. Expert opinion: Clinical results suggest that DMab is efficient both in systemic and articular bone loss in RA with limited side effects. Diminished bone erosion activity was also noted in RA patients on corticosteroids and bisphosphonates. Combination of DMab with an anti-TNF agent was not associated with increased infection rates. Collectively, these data indicate that DMab, in combination with methotrexate and possibly other conventional synthetic Disease Modifying Anti-Rheumatic Drugs (csDMARDs), is an effective, safe and cost-effective option for the treatment of RA.