Methotrexate-associated osteonecrosis of the jaw: A report of two cases

Medication-related osteonecrosis of the jaw (MRONJ) systemic review: mevalonate pathway mechanisms explored

Medication-related osteonecrosis of the jaw (MRONJ) is a rare, but devastating condition caused by bisphosphonates, receptor activator of nuclear factor kappa-B ligand inhibitors, anti-angiogenic medications, and disease-modifying antirheumatic drugs. While the clinical spectrum of MRONJ has a wide range, there is a subgroup of patients that do not improve with antibiotics and conservative surgical debridement resulting in pathologic fractures, draining fistulas, and/or osteomyelitis. For the severely affected individuals, the only cure is surgical resection with micro-vascular free flap reconstruction. The etiology of MRONJ is unknown because of the lack of understanding of the biological underpinnings of the disorder connected to the mechanisms of action of the various medications. This limited knowledge has resulted in the classification of patients by clinical presentation rather than underlying pathology. Therefore, the aim of this article is to present a mechanistic framework of MRONJ through the mevalonate pathway in the context of the medications that are known to induce it and explore potential novel therapeutics.

Volumetric analysis of spontaneous bone formation after segmental mandibulectomy in patients with MRONJ

OBJECTIVE

The purpose of this study was to quantify the spontaneous new bone formation and bony bridge formation by 3-dimensional analysis of cone-beam computed tomography (CBCT) after segmental mandibulectomy reconstruction using an R-plate without any graft material in patients with medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

15 MRONJ patients (13 females and 2 males) were selected based on the inclusion criteria. Data on new bone formation, bony bridge formation, R-plate fracture, patient age, and type and duration of medication were collected. Panoramic and CBCT scans were obtained at 1 day, 6, 12, and 24 months postoperatively. CBCT images of each period were transferred to a personal computer using MIMICS 21.0 for volumetric analysis. After quantifying the volume of new bone formation, we calculated the percentage of the volume of new bone to the segmentally resected necrotic bone volume (%NB).

RESULTS

All patients showed spontaneous new bone formation with the average of 20.69% within a year and 28.52% within 2 years, and 80.0% showed bony bridge formation within a year.

CONCLUSIONS

The R-plate reconstruction in patients with MRONJ showed significant amount of spontaneous new bone formation within 2 years after segmental mandibulectomy.

Risk of healing impairment following tooth extraction in patients administered with antiresorptive and non-antiresorptive polypharmacy

INTRODUCTION

Lack of evidence existed related to the essential role by which anticancer medications alone or in combination with other polypharmacy would be accountable for wound healing impairment post-dental extraction. The following study was conducted to assess the influence of antiresorptive (AR) and non-antiresorptive (non-AR) drugs and other patient-related risk factors on wound healing status following tooth extraction.

MATERIAL AND METHODS

A total of 353 patients (age range: 40-90 years, average age: 67.4 years, clinical and radiological follow-up) were recruited. All the patients were divided into three groups, which included, patients used polypharmacy with non-AR drugs, polypharmacy with a combination of AR + non-AR drugs, and the control group. Based on time of healing, the outcome was defined as, normal healing, delayed healing, and Medication-related osteonecrosis of the jaw (MRONJ). The polypharmacy score was categorized depending on the sum of the number of administered medications.

RESULTS

The odds of delayed healing were significantly higher in 80+ years old patients (OR=6.98, 95 %CI:2.45-19.88, p = < 0.001) administered with AR+ non-AR drugs (OR=14.68, 95 %CI:4.67-46.14, p = < 0.001), having a major polypharmacy score (OR= 15.37, 95 %CI:4.83-48.91, p = < 0.001). On the contrary, patient administered with non-AR drugs (OR=11.52, 95 %CI: 4.45-29.83, p = < 0.001) with hyper polypharmacy (OR=58.86, 95 %CI:25.03-138.40, p = < 0.001) were significantly more likely to develop MRONJ. Smoking and extraction sites showed no significant impact on wound healing impairment.

DISCUSSION

Wound healing status in patients administered with both non-AR and AR+ non-AR polypharmacy was significantly impaired following tooth extraction. Other risk factors, such as increased age and high polypharmacy scoring, also significantly contributed towards the occurrence of delayed healing and MRONJ.

Effect of agents affecting bone homeostasis on short- and long-term implant failure

OBJECTIVES

To review the current evidence on the relationship between agents that affect bone homeostasis and dental implant failures.

MATERIALS AND METHODS

Electronic searches for bisphosphonates, denosumab, methotrexate, corticosteroids, romosozumab, sunitinib, and bevacizumab were performed using PubMed, MEDLINE (OVID), EMBASE (OVID), Cochrane Central Register of Controlled Trials (Cochrane Library), Cochrane Oral Health Group Trials Register (Cochrane Library) and Web of Science (Thomson Reuters). Manual searches were also conducted to complement the digital searches for recent issues.

RESULTS

Previous publications suggested that bisphosphonates do not compromise the survival of dental implants. However, one study documented an increased risk of implant failure in patients who had received high-dose of intravenous bisphosphonate therapy after implant rehabilitation. There has been an issue of MRONJ around implants in patients who have successfully received implant therapy before and after antiresorptive therapy, leading to late implant failure. Despite evidence on the detrimental effects of denosumab, methotrexate and corticosteroids on bone metabolism, their role in implant survival is not conclusive.

CONCLUSIONS

At present, there is insufficient evidence to establish a potential connection between agents that affects bone homeostasis and implant failure. However, some studies have reported negative results for implant therapy. In addition, implant-related sequestration in patients who received anti-resorptive therapy, despite of successful osseointegration, is also noticeable. Although limited studies are available at present, clinicians should still carefully consider the potential hazards and take appropriate precautions to minimize the risks associated with the medications and implant therapy.

Medication-Related Osteonecrosis: Why the Jawbone?

Medication-related osteonecrosis of the jaw (MRONJ) has emerged as a complication of anti-resorptive medications. Despite its low incidence rate, this problem has gained attention in recent years due to its devastating consequences and lack of preventive strategy. The fact that MRONJ incidence has been exclusive to the jawbones, despite the systemic effect of anti-resorptive medications, could be a starting point to unravel the multifactorial pathogenesis of this condition. This review aims to negotiate the question of why the jawbone is more susceptible to MRONJ than other skeletal sites. Approaching the problem from this perspective could provide new directions for the prevention of MRONJ and expand our understanding of the unique oral microenvironment.

Possible association of methotrexate use with osteonecrosis of the jaw: Systematic review

The aim was to search systematically, evaluate, and then summarize scientific literature about possible methotrexate-associated osteonecrosis of the jaw (ONJ), its signs and symptoms, diagnosis, treatment, and prognosis in adults. After registration at PROSPERO this systematic review was conducted and reported according to the PRISMA checklist. The following databases were systematically searched: MEDLINE, EBSCO, The Cochrane Central Register of Controlled Trials (Central), SCIndex, Scopus, Google Scholar and Registry of clinical studies with human participants. In total 9 studies with 14 patients were included in the review. All cases of ONJ associated with methotrexate were described in patients suffering from Rheumatoid arthritis (RA), and only about 40% of them were taking other concomitant medication described to be associated with ONJ (bisphosphonates). Both sexes were equally affected, and the patients were rather old (over 60 years if age), already taking methotrexate for more than 12 years on average. Antibiotics were ineffective in the treatment of ONJ; after stopping methotrexate, all lesions healed after several months on average; however, half of the cases required covering of the exposed bone with mucosal flap. Recurrence of the methotrexate-associated ONJ was not observed for at least two years after the lesions were healed. Methotrexate-associated ONJ is serious clinical condition that may occur in patients with RA, but given the small number of cases we have found in the literature, direct involvement of methotrexate in the development of ONJ remains elusive.

The impact of sex steroids on osteonecrosis of the jaw

Sex steroid hormones play a major role in bone homeostasis. Therefore, the use of sex hormones or drugs may increase the risk of osteonecrosis of the jaw (ONJ), a complication caused by damaged bone homeostasis. However, few are known the impact of medications changing sex hormone levels on ONJ.

The pathophysiology of ONJ is not clearly understood and many hypotheses exist: cessation of bone remodeling caused by its anti-resorptive effect on osteoclasts; compromised microcirculation due to medication affecting angiogenesis, including bisphosphonate; and impairment of defense mechanism toward local infection.

The use of high-dose intravenous bisphosphonate in cancer patients is associated with a high prevalence of ONJ. Exogenous estrogen or androgen replacement was reported to be associated with ONJ. Polycystic ovarian syndrome (PCOS) patients demonstrate an androgen excess status, and androgen overproduction serves as a protective factor in the bone mineral density of young women. To date, there are no reports of ONJ occurrence due to androgen overproduction. In contrast, few reports on the occurrence of ONJ due to estrogen deficiency induced by drugs, such as selective estrogen receptor modulator (SERM), aromatase inhibitors, and gonadotropin-releasing hormone (GnRH) agonists, are available.

Thus, the role of sex steroids in the development of ONJ is not known. Further studies are required to demonstrate the exact role of sex steroids in bone homeostasis and ONJ progression. In this review, we will discuss the relationship between medication associated with sex steroids and ONJ.

A Retrospective Data Analysis for the Risk Evaluation of the Development of Drug-Associated Jaw Necrosis through Dentoalveolar Interventions

This study aimed to analyse the development of medication-related osteonecrosis of the jaw (MRONJ) in patients who underwent surgical intervention to identify potential risk factors between three different groups sorted by the type of oral surgery (single tooth extraction, multiple extraction, osteotomy). Data from patients with this medical history between 2010 and 2017 were retrospectively analysed. The following parameters were collected: sex, age, medical status, surgical intervention location of dentoalveolar intervention and form of medication. A total of 115 patients fulfilled the criteria and underwent 115 dental surgical interventions (female n = 90, male n = 25). In total, 73 (63.47%) of them had metastatic underlying diseases, and 42 (36.52%) had osteoporotic ones. MRONJ occurred in 10 patients (8.70%) (female n = 5, male n = 5). The occurrence of MRONJ was significantly correlated (p ≤ 0.05) with the mandible site and male sex. Tooth removal at the mandible site remains the main risk factor for the development of MRONJ. The risk profile of developing MRONJ after dentoalveolar interventions could be expected as follows: tooth osteotomy > multiple extractions > single tooth extraction.

Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications

Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.

Impact of COVID-19 disease and its treatment on the development of maxillofacial complications

The novel coronavirus spread worldwide in 2020, causing millions of deaths and disabilities. Even though the virus was considered a respiratory virus, its adverse effects can be detected in several body systems. The article describes COVID-19 disease and its complications in the maxillofacial area. Several complications develop either in response to therapeutic modalities used to treat the underlying disease, or due to overuse of particular medications namely glucocorticoids, antirheumatic agents, interleukin 6-inhibitors, and antibiotics. This article will describe a number of complications ranging from mild complications to severe ones such as osteonecrosis of the upper jaw and facial bones, ophthalmologic and neurological complications. It will also summarize recommendations that will help prevent or minimize these complications.

Recent perspectives on the association between osteonecrosis and bone mineral density decline in childhood acute lymphoblastic leukemia

The attention to treatment-related toxicity has increased since the survival of children with acute lymphoblastic leukemia (ALL) has improved significantly over the past few decades. Intensive ALL treatment schedules including corticosteroids and asparaginase have been shown to give rise to skeletal abnormalities such as osteonecrosis and low bone mineral density (BMD), which may lead to debilitating sequelae in survivors. Although osteonecrosis and low BMD are different entities with suggested separate pathophysiological mechanisms, recent studies indicate that osteonecrosis is associated with accelerated BMD decline. Common underlying mechanisms for osteonecrosis and BMD decline are considered, such as an enhanced sensitivity to corticosteroids in children who suffer from both osteonecrosis and low BMD. In addition, restriction of weight-bearing activities, which is generally advised in patients with osteonecrosis, could aggravate BMD decline. This induces a clinical dilemma, since bone stimulation is important to maintain BMD but alternative interventions for osteonecrosis are limited. Furthermore, this recent finding of accelerated BMD decline in children with osteonecrosis emphasizes the need to develop effective preventive measures for osteonecrosis, which may include targeting BMD decline.

The prosthodontic management of medication-related osteonecrosis of the jaw: a case report

Medication-related osteonecrosis of the jaw (MRONJ) has clear staging and management guidance from the American Association of Oral and Maxillofacial Surgeons. There is, however, less guidance on the prosthodontic rehabilitation for this cohort of patients. This paper aims to bring increased understanding on the staging of MRONJ as well as approaches to its prosthodontic management. This case report outlines a removable prosthodontic method that successfully rehabilitated a patient suffering from MRONJ. This case is well documented with the use of clinical photography. The article demonstrates techniques in overcoming the challenges of necrotic bone in the denture-bearing area, and how such methods can improve both tissue health and patient symptoms.

Medication-related osteonecrosis of the jaw: Analysing the range of implicated drugs from the Australian database of adverse event notifications

AIMS

Medication-related osteonecrosis of the jaw (MRONJ) is an uncommon but potentially debilitating condition, characterised by nonhealing jawbone, with or without mucosal exposure, in the presence of certain drugs. Those already strongly associated with MRONJ include antiresorptives denosumab and bisphosphonates; however, a growing range of other non-antiresorptive drugs is implicated. The aim of this study was to analyse all case reports of MRONJ submitted to the publicly available Database of Adverse Event Notification from the Therapeutic Goods Administration in Australia.

METHODS

The Therapeutic Goods Administration was contacted on 6 January 2020 and asked for all reports containing the words "osteonecrosis of the jaw". This was provided in a spreadsheet of de-identified reports received from commencement of the database in 1971 until 1 October 2019.

RESULTS

The drugs implicated in the 419 cases were divided by established drugs with MRONJ and secondary drugs that possibly contribute to MRONJ development. While the majority of cases were associated with denosumab or bisphosphonates (n = 405), there were 14 reports where secondary agents that directly or indirectly affect bone turnover, were also implicated. Some of these secondary drugs, including adalimumab, etanercept, methotrexate and rituximab have previously been associated with MRONJ in published case reports.

CONCLUSIONS

This study contributes to the sparse but growing literature associating an increasing number of drugs with MRONJ, and underscores the importance of considering all possible drugs that elevate a patient's MRONJ risk.

Review and update on drugs related to the development of osteonecrosis of the jaw

Background

Medication-related osteonecrosis of the jaw (MRONJ) is a rare, but serious adverse effect of certain drugs, of which bisphosphonates are the most widely known. This pathology is also associated with other medications such as the biologic antiresorptive agent, denosumab and some antiangiogenics such as sunitinib, bevacizumab or aflibercept. Very recently, new medications have also been associated with osteonecrosis of the jaw (ONJ). The objectives were to update the list of medications associated with ONJ, to analyze the fundamental aspects of this list and to describe the level of evidence available.

Material and Methods

A narrative bibliographic review was made, using the PubMed-MedLine, DOAJ and SCIELO databases. Additional information was obtained through the online Medication Information Centre of the Spanish Agency of Medicines and Medical Devices (AEMPS – CIMA), the websites of the US Food & Drugs Administration (Drugs@FDA) and the European Medicines Agency (EMA).

Results

The latest drugs identified as potential facilitators of this pathology include a number of anti-VEGF based antiangiogenic drugs and anti-TKI and different types of immunomodulators. Neither the level of evidence in this association nor the risk are equal for all these drugs. On the other hand, over the coming years, new drugs will be marketed with similar action mechanisms to those that are recognized as having this adverse effect.

Conclusions

No effective therapy is currently known for the treatment of ONJ. Therefore, in order to prevent new cases of MRONJ, it is essential for all oral healthcare professionals to be fully up-to-date with the etiopathogenic aspects of this pathology and to be aware of those drugs considered to be a risk.

Key words:Osteonecrosis of the jaw, MRONJ, bisphosphonates, antiresorptives, antiangiogenics.

Novel insight into the management of bisphosphonate-related osteonecrosis of the jaw (BRONJ)

Bisphosphonate-related osteonecrosis of the jaw (BRONJ), characterized by refractory bone exposure, has recently emerged as a serious side effect of bisphosphonate (BPs) treatment. We discuss novel insights that may help to improve the efficacy of BRONJ treatment and prevention. Our report highlights the following: (1) The presence of exposed bone in patients taking BPs does not necessarily reflect BRONJ, and diagnoses of oral ulceration with bone sequestration and malignancy must be excluded. (2) Osteonecrosis type of BRONJ is difficult to avoid using preventive dental measures alone. However, as with osteomyelitis type of BRONJ, preventive dental measures are indispensable for reducing the risk of secondary infection and disease progression. (3) The importance of tooth extraction as a risk factor for BRONJ among patients taking BPs has been overstated, particularly when they are administered at low doses. Delaying tooth extraction may increase the risk for the onset and progression of osteomyelitic BRONJ. (4) In patients taking low doses of BPs, dental implant surgery is not necessarily contraindicated if there are no other risk factors, such as combined use of corticosteroids or concomitant diabetes. However, the risk of BRONJ due to peri-implantitis must be explained when obtaining patient consent.

Spontaneous bilateral osteonecrosis of the mandible in a bisphosphonate-naive patient

Medication-related osteonecrosis of the jaw is a well-described, yet poorly understood disease of bone that is commonly associated with antiresorptive and antiangiogenic drugs. We report a case of spontaneous bilateral osteonecrosis of the mandible in a patient with no previous exposure to either.

[Current situation and future issues of antiresorptive agent-related osteonecrosis of the jaw]

Bisphosphonate-related osteonecrosis of the jaw (BRONJ), which is characterized by refractory bone exposure, has recently emerged as a serious side effect of bisphosphonate (BP) treatment. BRONJ was first thought to be due to administration of high doses of intravenous BP to treat metastatic bone lesions or multiple myeloma. However, more recent studies have indicated that BRONJ also frequently occurs in patients receiving low doses of BP for the treatment of osteoporosis. In addition, patients treated with denosumab, a human monoclonal antibody against receptor activator of nuclear factor-kappa B ligand (RANKL) whose antiresorptive effects differ from those of BP, may develop osteonecrosis of the jaw. Since both BP and denosumab are associated with osteonecrosis of the jaw (ONJ), antiresorptive agent-related ONJ (ARONJ) has been suggested as a comprehensive term. Although the pathophysiology of BRONJ remains unclear and the number of affected patients is increasing in Japan, significant improvements have been made with respect to risk reduction strategies and treatment. Despite the publication of the first position paper on BRONJ in Japan in 2010, an increase of the number of patients of BRONJ is hypothesized to result from an increase in the long-term use of BP. Previous findings have suggested that inadequate preventive measures including restriction of tooth extraction may be responsible for increases in BRONJ incidence.

Medication-related osteonecrosis of the jaw unrelated to bisphosphonates and denosumab-a review

The link between medication-related osteonecrosis of the jaw (MRONJ) and bone modulating drugs, such as bisphosphonates and denosumab, is well established, and the number of reported cases is increasing. The development of novel medications used in the treatment of cancer, as well as autoimmune and bone conditions, has led to more cases of MRONJ being reported. However, in addition to this group of medications, increasing numbers of new agents in cancer therapy, such as antiangiogenic agents, have also been implicated in the development of MRONJ. As these newer agents with similar mechanisms are routinely used, the numbers of reported cases will likely rise further. This article aims to identify and summarize the drugs implicated in MRONJ, besides bisphosphonates and denosumab. A wide range of medications classified as tyrosine kinase inhibitors, monoclonal antibodies, mammalian target of rapamycin inhibitors, radiopharmaceuticals, selective estrogen receptor modulators, and immunosuppressants have been implicated in MRONJ. It remains crucial that oral health care providers are aware of these new medications and their associated risks to manage their patients appropriately.

Low-dose methotrexate in rheumatoid arthritis: a potential risk factor for bisphosphonate-induced osteonecrosis of the jaw

Bisphosphonate-induced osteonecrosis of the jaw [BIONJ] is a relatively new pathological condition which was first described in the year 2003. The prevalence of BIONJ in patients on oral formulations is around 0.05% within the first 3 years and increases up to 0.2% after 4 years of consumption. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases [e.g., high doses of methotrexate up to 30 mg daily] significantly increase the chances of acquiring BIONJ. We present three patients with osteoporosis and rheumatoid arthritis [RA] who consumed oral bisphosphonates [alendronate] for less than 1 year and developed BIONJ within 2 to 5 months of undergoing a traumatic dental procedure. The patients also gave a history of consuming low doses of methotrexate [disease-modifying anti-rheumatic drugs] up to 20 mg weekly for 4 to 10 years. No history of steroid consumption was given by any of the patients. This case series highlights the possibility of rheumatoid arthritis and low-dose methotrexate being potential risk factors for BIONJ. This may be on account of the synergistic effect of methotrexate and bisphosphonates and the pro-inflammatory state created by RA which increased the risk of acquiring BIONJ.